abses peritonsilar medscape 1.docx

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Background

Peritonsillar abscesses (PTAs) are common infections of the head and neck region andcomprise approximately 30% of soft tissue head and neck abscesses.[1] Physicians must beaware of the typical clinical presentation and diagnostic strategies in order to quicklydiagnose and appropriately treat these patients to prevent complications and further

propagation of the infectious process.

A peritonsillar abscess is shown in the image below.

Right peritonsillar abscess. The soft palate, which iserythematous and edematous, is displaced anteriorly. The patient has a "hot potatosounding"voice.

Pathophysiology

The 2 palatine tonsils are on the lateral walls of the oropharynx in the depression between theanterior and posterior tonsillar pillars. Each pillar is composed primarily of the glossopalatine

and the pharyngopalatine muscles.

During embryonic development, the tonsils arise from the second pharyngeal pouch as budsof endodermal cells.[2] The tonsils then grow irregularly and reach their ultimate size andshape at approximately age 6-7 years.

Each tonsil is surrounded by a capsule, a specialized portion of the intrapharyngealaponeurosis that covers the medial portion of the tonsils and provides a path for blood vesselsand nerves.[2] It is within this potential space between the tonsil and capsule that peritonsillarabscesses form.[3]Note that the peritonsillar space is anatomically contiguous with severaldeeper spaces, and infections can potentially involve the parapharyngeal and retropharyngeal

spaces.[4]

Peritonsillar abscesses usually progress from tonsillitis to cellulitis and ultimately to abscessformation. Weber glands are thought to also play a key role in the etiology of the infection.These mucous salivary glands are located superior to the tonsil in the soft palate and clear thetonsillar area of debris. If these glands become inflamed, local cellulitis develops. As theinfection progresses, inflammation worsens and results in tissue necrosis and pus formation,most commonly just above the superior pole of the tonsil where the glands are located.[3]

Epidemiology

Frequency
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United States

In the United States, the incidence of peritonsillar abscess has been estimated at 30 cases per100,000 persons per year, accounting for approximately 45,000 cases annually.It has also

been estimated to result in at least $150 million a year in health care expenditures.[5] Most

infections occur during November to December and April to May, which coincide with thehighest incidence rates of streptococcal pharyngitis and exudative tonsillitis.[3]

International

A higher rate due to recurrence and antibiotic resistance is reported internationally.

Mortality/Morbidity

Mortality of peritonsillar abscess is unknown.

Morbidity of peritonsillar abscess is due mostly to pain, cost of treatment, lost time fromwork and school, and complications.

Race

No racial predilection of peritonsillar abscess is noted.

Sex

The male-to-female ratio of peritonsillar abscess is equal.

Age

Peritonsillar abscess can occur in anyone aged 10-60 years according to one source, althoughperitonsillar abscess is most commonly seen in those aged 20-40 years.[6] The youngerchildren who get peritonsillar abscess are often immunocompromised.

History

Symptoms of peritonsillar abscess usually begin 3-5 days prior to evaluation.

Fever Malaise Headache Neck pain Throat pain markedly more severe on the affected side and occasionally referred to

the ipsilateral ear Dysphagia Change in voice Otalgia Odynophagia


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Physical

Physical findings of peritonsillar abscess include the following:

Mild/moderate distress Fever Tachycardia Dehydration Drooling, salivation, trouble handling oral secretions Trismus resulting from pain from inflammation and spasm of masticator muscles Hot potato/muffled voice Rancid or fetor breath Cervical lymphadenitis in the anterior chain Asymmetric tonsillar hypertrophy Localized fluctuance

Inferior and medial displacement of the tonsil Contralateral deviation of the uvula Erythema of the tonsil Exudates on the tonsil

Causes

Peritonsillar abscesses are usually polymicrobial. A recent prospective study carried out toelucidate significant pathogens involved in peritonsillar abscesses demonstrated that the most

prominent aerobic pathogen was Streptococcus pyogenes. Other aerobic pathogens isolatedincluded Staphylococcus aureus,Neisseria species, and Corynebacterium species. In the samestudy, the most common anaerobic species found wasFusobacterium necrophorum, anobligate, anaerobic, Gram-negative rod. OtherFusobacterium species andPrevotella specieswere also isolated. Though the study was carried out in Denmark, studies within the UnitedStates have demonstrated similar results.[3, 7, 2, 8]

Laboratory Studies

No definitive studies are required for the diagnosis of peritonsillar abscess, although onemight consider obtaining CBC count and electrolyte evaluations if the patient had significantcomorbidities.

Monospot test/heterophile antibody test can be performed to rule out infectiousmononucleosis if the etiology is unclear.

Culture of fluid from needle aspiration may be performed.

Blood cultures may be indicated if the clinical presentation is severe.

Imaging Studies

Lateral soft tissue neck radiographs may help rule out other causes. The anteroposterior (AP)view of the neck may demonstrate distortion of soft tissue.


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Intraoral ultrasonography (US) has a sensitivity of 95.2% and specificity of 78.5%. Thismethod is cost-effective and fast, although it does require a cooperative patient. A recentstudy carried out at an academic level I emergency department included 43 patients whoreceived intraoral US for suspected peritonsillar abscess. Thirty-five were diagnosed with anabscess on US, and these patients subsequently received needle aspiration using US guidance.

There was one false positive, but no patients returned unexpectedly after drainage, and, onreexamination, there was no evidence of persistent or recurrent peritonsillar abscess orcellulitis. This study supports the use of US for both the diagnosis and treatment of

peritonsillar abscesses.[9] Prior studies of US use have shown similar successful results.

Head and neck CT scanning with intravenous (IV) contrast is useful if incision and drainagefails, if the patient cannot open his or her mouth, or if the patient is young (< 7 y) anduncooperative. A hypodense fluid collection with rim enhancement may be seen in theaffected tonsil. Foreign bodies, such as fish or chicken bones, may also be found as aninciting factor.

Procedures

Three options are available for acute surgical management of peritonsillar abscess: needleaspiration, incision and drainage, and quinsy tonsillectomy (eg, simultaneous tonsillectomywith open abscess drainage).

A systematic review by Johnson et al attempted to determine the best technique for acutesurgical management. Forty-two articles were analyzed. Five level I clinical studies indicatedthat all 3 techniques were equally effective for initial management.[10]

Needle aspiration

The main advantage of needle aspiration is ease of the procedure, decreased pain for thepatient, and cost-effectiveness.[5, 10]

The patient should be sitting upright.

Lidocaine with epinephrine should be used to anesthetize the area.

A 16- to 18-gauge needle with a 10-mL syringe should be used to aspirate from the area thatis most fluctuant.

A needle guard may be used to prevent accidental carotid artery puncture due to the tip of theneedle migrating too far posteriorly. Only 0.5 cm of the needle needs to be exposed. If aneedle guard is unavailable, a curved clamp can be used to expose a small portion of theneedle before inserting it into the area for aspiration.

Aspirate at the superior pole initially, as this is the most common place for abscessdevelopment. Aspiration of the middle one third and then the lower one third should then beattempted if pus is not returned from the superior pole. Also, seeDrainage, PeritonsillarAbscess.
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Pus is aspirated through a wide-bore needle from the rightperitonsillar abscess. An additional incision will be made to drain any other pus pockets.

Abscess incision and drainage[11]

The patient should be sitting upright with a pan available to spit out any blood or pus.

A tongue depressor is used to retract the tongue.

After local infiltration with lidocaine with epinephrine, a No. 11 blade scalpel is used to makea small incision 0.5 cm long and no more than 1 cm deep. Be certain that the incision is notextended laterally as the carotid artery lies in that vicinity.

Use a small hemostat to probe the abscess and release the pus.

To prevent the risk of aspiration, allow the patient to hold the Yankauer catheter tip and tosuction the pus.

Tonsillectomy

No clear evidence indicates that routine elective tonsillectomy is indicated to prevent futureperitonsillar abscesses. However, if the patient has had multiple recurrent episodes ofperitonsillar abscessor has other clear indications such as sleep-disordered breathing, electivetonsillectomy should be considered.[5]

Additionally, ifgeneral anesthesiais required because of the patient's age or lack ofcooperation, tonsillectomy should be considered, as the complication rate is low and althoughthe data do not support this, consideration for the most definitive procedure should bemade.[5, 10]

Prehospital Care

Prehospital care for peritonsillar abscess includes transport with supplemental oxygen.

Emergency Department Care

ABCs, paying attention to the patient's airway, should be evaluated. If the patient's airway iscompromised, he or she needs immediate endotracheal intubation. If this cannot becompleted, a cricothyroidotomy or a tracheotomy may be required. Alternatively, if theresources are available, one study concluded that awake fiberoptic bronchoscopy was the

method of choice for intubating patients with significant pharyngeal edema.[5]
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These patients are often dehydrated because of their avoidance of food and liquid and mayneed fluid resuscitation.

Antipyretics should be administered for elevated temperature, and adequate analgesia shouldbe provided for pain.

Acute surgical management should be carried out as discussed above.

Empiric antibiotics should be administered.

Steroids are often used as adjunctive treatment. In the systematic review carried out byJohnson et al, no published studies on the use of steroids in peritonsillar abscess were found,

but the authors did identify a randomized controlled trial that demonstrated a benefit forsteroids for severe, acute pharyngitis. It is likely that the use of steroids for PTA derived fromthis management strategy

Patients can be managed in an outpatient setting unless they show signs of toxicity, sepsis,airway compromise, inability to swallow, or other complications.

Consultations

An otolaryngologist may be required if the patient's presentation is severe. Ananesthesiologist or surgeon may be required for management of a difficult airway.

Medication Summary

Antibiotics are the main component of therapy.

Begin antibiotic therapy prior to needle aspiration and report of culture results.

Though several studies have shown intravenous penicillin alone is clinically effective(provided the abscess is adequately drained), other studies have reported that greater than50% of cultures grow beta-lactamase producing anaerobes, leading to the tendency to use

broader-spectrum antibiotics such as clindamycin or a second- or third-generation oralcephalosporin.

In those patients allergic to penicillin, clindamycin is a good choice.

Analgesics and throat washes are recommended.

As mentioned above, some physicians report using adjunctive steroids to decrease edema andpain.

Antibiotics

Class Summary


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Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogensin the context of the clinical setting.

Clindamycin (Cleocin)

Semisynthetic antibiotic produced by 7(S)-chloro-substitution of 7(R)-hydroxyl group ofparent compound lincomycin. Inhibits bacterial growth, possibly by blocking dissociation ofpeptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Widelydistributes in the body without penetration of CNS. Protein bound and excreted by the liverand kidneys.

Oral or parenteral antibiotic for anaerobic or susceptible streptococcal, pneumococcal, orstaphylococcal species. Considered to have good absorption into bloodstream in both oral and

parental forms.

Penicillin G benzathine (Bicillin L-A)

DOC in combination with metronidazole. Effective in approximately 98% of patients.Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in

bactericidal activity against susce

Metronidazole (Flagyl)

DOC in combination with penicillin. Effective in approximately 98% of treated patients.

Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa.

Appears to be absorbed into the cells of microorganisms that contain nitroreductase. Unstableintermediate compounds are formed that bind DNA and inhibit synthesis, causing cell death.

Nafcillin (Unipen)

Initial therapy for suspected penicillin G-resistant streptococcal or staphylococcal infections.

Use parenteral therapy initially in severe infections. Change to PO therapy as conditionwarrants.

Because of thrombophlebitis, particularly in elderly persons, administer parenterally only for

short term (1-2 d); change to PO route as clinically indicated.

Erythromycin (E.E.S, Ery-Tab, Erythrocin)

Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA fromribosomes, causing RNA-dependent protein synthesis to arrest. For treatment ofstaphylococcal (including S aureus) and streptococcal infections.Indicated if patient isallergic to penicillin.

Further Inpatient Care
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Observation, imaging studies, airway management, and intravenous hydration may berequired.

Other methods of operative management strategy may be indicated and should be performedby an otolaryngologist.

Recurrence obviates the need for a second hospitalization for interval tonsillectomy afterneedle decompression or incision and drainage.

To prevent recurrence, interval tonsillectomy may be considered 3-4 weeks after resolution ofedema and symptoms.

Further Outpatient Care

If outpatient care is used, the patient can be discharged on an appropriate regimen of

antibiotics and pain medications.

Relative indications for elective tonsillectomy can be identified in almost a third of allpatients who present with paratonsillar abscess (eg, recurrent tonsillitis).

Complications

Complications of peritonsillar abscess may include the following:

Necrotizing soft tissue infection of the neck and chest wall[12]

Recurrence Aspiration, which may lead to pneumonia or pneumonitis Cervical abscess Mediastinitis Meningitis Sepsis Cerebral abscess Jugular vein thrombosis Carotid artery rupture/necrosis Carotid artery injury (from I&D or needle aspiration)

Prognosis

Uncomplicated, treated peritonsillar abscess has a resolution rate of 94%. In the UnitedStates, the recurrence rate is 10%, although this rate jumps to 15% internationally.

Patient Education

For patient education resources, see theEar, Nose, and Throat Center, as well asPeritonsillarAbscess,Tonsillitis, andAntibiotics.

References
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