Peritonsillar Abscess

Peritonsillar abscess (PTA) is the most frequently occurring deep-space infection of the head and neck. 1314 It is an acute, usually infectious, accumulation of purulent material between the tonsillar capsule and the superior constrictor muscle of the pharynx ( Fig,.235-2). It is thought to be a complication of follicular tonsillitis that progresses from local cellulitis to abscess. A secondary mechanism of abscess development may occur through seeding of bacteria throughout the tonsil via the bloodstream or lymphatics.15

Peritonsillar

FIG. 235-2. A. In tonsillitis, the tonsils are enlarged. They may be covered by white exudate. The margin between the tonsil and the anterior tonsillar pillar is well defined. B. In peritonsillar abscess, the tonsil, palate, and anterior tonsillar pillar may be bulging medially in one unit. The margin between the tonsil, palate, and anterior tonsillar pillar is somewhat effaced. The uvula is usually edematous and may be pointing toward the opposite tonsil. The safest area to aspirate a peritonsillar abscess is usually just above the tonsil in the soft palate. This location will serve to guard the deep vessels of the neck from inadvertent injury. (From Abelson TI, Witt WJ, in Roberts jR, Hedges JR, eds: Clinical Procedures in Emergency Medicine, 2d ed. Philadelphia, Saunders, 1991, with permission.)

PTAs are more common during the second and third decades.13 The incidence of PTAs corresponds to the incidence of streptococcal pharyngitis and tonsillitis, occurring with greatest frequency from November to December and from April to May.

Cultures of aspirates from PTAs characteristically produce a mixture of aerobic and anaerobic flora. 16 The most predominant infective organisms in PTAs are S. pyogenes, Bacteroides, Peptostreptococcus, and Staphylococcus aureus.1 l6 b-lactamase producing organisms are present in up to one half of all culture specimens.14

Symptoms of a PTA include fever, malaise, "hot-potato voice," sore throat, odynophagia, dysphagia, and otalgia. Signs of a PTA include dehydration, unilateral tonsillar hypertrophy, palatal edema, contralateral deflection of the swollen uvula, inferior and medial displacement of the infected tonsil, tender cervical lymphadenopathy, drooling, rancid breadth, and trismus (Fig 235-3).

FIG. 235-3. Open-mouth view with mouthgag present in a patient demonstrating tonsillar hypertrophy, palatal edema, and uvula deviation consistent with a peritonsillar abscess.

The differential diagnosis of a PTA includes cellulitis, infectious mononucleosis, herpes simplex tonsillitis, retropharyngeal abscess, neoplasm, foreign body, and internal artery carotid aneurysm.

The diagnostic gold standard of a PTA is aspiration of pus through an 18-gauge needle. This should be done by individuals trained in the technique who can manage complications of the procedure. Prior to aspiration lidocaine spray or gel is used to anesthetize the overlying mucosa topically. Then, 1 to 2 mL lidocaine with epinephrine, using a 25-gauge needle, can be injected into the mucosa of the anterior tonsillar pillar. Once adequate anesthesia is achieved, an 18-gauge needle should be directed medially and superiorly within the abscess cavity. The needle should penetrate no more than 1 cm. A needle guard can be made by cutting the distal tip of a needle cover and replacing it over the needle so that less than 1 cm of the needle is exposed. Note that the carotid artery lies laterally and inferiorly, and care should be taken to avoid this area. Often, multiple aspirations may be required to find the abscess. Attempts should first begin on the superior aspect of the anterior tonsillar pillar and then progress inferiorly. Any pus aspirated should be sent for Gram stain, aerobic cultures, and anaerobic cultures. Children with trismus in whom adequate examination is not possible should be brought to the operating room and examined under anesthesia. When the airway is not in jeopardy and either a complete examination or aspiration is not possible, a computed tomography (CT) scan of the neck may be required to better evaluate this area.

The majority of PTAs can be treated effectively with outpatient needle aspiration, antibiotics, and pain medication. Incision and drainage or tonsillectomy can be performed when needle aspiration fails. A contrast CT scan of the neck is recommended when the results of needle aspiration are negative and a parapharyngeal- or retropharyngeal-space process is suspected. A PTA in a child requires hospitalization, intravenous hydration, antibiotics, and removal of the abscessed tonsil under general anesthesia. High-dose penicillin is the drug of choice, although, in light of current microbiologic findings of penicillin-resistant organisms, treatment with penicillin alone may be ineffective. Ampicillin-sulbactam, clindamycin, cefotaxime, and metronidazole should be considered. Ten days of antibiotics after aspiration is usual. Previous antibiotic treatment does not always prevent the development of peritonsillar abscess. Many patients presenting with peritonsillar abscess have been treated with antibiotics at the time of presentation.

Complications of a PTA include airway obstruction, rupture of the abscess with aspiration of the contents, thrombophlebitis, ulceration of the large submaxillary arteries, epiglottitis, septicemia, endocarditis, retropharyngeal abscess, and mediastinitis.

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