Peritonsillar Abscess Workup

  • Author: Benoit J Gosselin, MD, FRCSC; Chief Editor: John Geibel, MD, DSc, MA   more...
 
Updated: Feb 4, 2010
 

Laboratory Studies

  • CBC count, electrolyte level, blood culture: Patients presenting with PTAs often are septic in appearance and may demonstrate varying degrees of dehydration due to abstention from oral intake. Assessment of these 2 entities should involve the collection of blood for a complete blood count, electrolyte level measurement, and blood cultures.
  • Monospot test
    • In patients presenting with tonsillitis and bilateral cervical lymphadenopathy, a Monospot test (heterophile antibodies) should be considered.
    • If the test results are positive, the patient requires careful evaluation of hepatosplenomegaly. Liver function tests should be considered in patients with hepatomegaly.
  • Throat culture: To facilitate the identification of infectious organisms, a throat swab and culture are to be considered. The results may assist in selection of the most appropriate antibiotic once the organism is identified, limiting the risk of antibiotic resistance.
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Imaging Studies

  • Imaging may be particularly useful in cases where an attempt at I&D has failed or where worsening edema in a treated peritonsillar cellulitis is noted. In certain cases, the abscess may be within the tonsil itself and/or partially hidden (ie, inferior or posterior) by the tonsil.
  • Plain radiographs
    • Lateral soft tissue views of the nasopharynx and oropharynx may help the clinician rule out a retropharyngeal abscess.
    • In the anteroposterior view, the films reveal distortion of soft tissues but are not useful in localizing an abscess.
  • Computed tomography (CT) scanning
    • In selected clinical settings and in very young patients, radiological evaluation may be performed with a CT scan of the oral cavity and neck using intravenous contrast enhancement.
    • Common findings are the presence of a hypodense fluid collection in the apex of the affected tonsil, with peripheral rim enhancement.
    • Other findings may include an asymmetric enlargement of the tonsils and surrounding fossa.
    • Further delineation of cervical adenopathy is facilitated, as is the identification of a possible intranodal fluid collection, which indicates a cervical abscess and helps in the planning of surgical management.
  • Ultrasonography[4]
    • Intraoral ultrasonography has been proposed as an imaging modality. It is a simple, well-tolerated, noninvasive technique that can help distinguish between cellulitis and the presence of an abscess.
    • This also allows the option of a more directed aspiration of the tonsillar fossa before definitive surgical drainage is attempted. One study has shown that this approach is also clinically useful in the evaluation of patients presenting in the emergency department.
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Diagnostic Procedures

  • Needle aspiration
    • A needle aspiration of the abscess site may be performed just prior to attempting the drainage procedure. It allows identification of the location of the abscess in the peritonsillar space.
    • The aspiration site is anesthetized using lidocaine with epinephrine, and a large-bore (#16- to 18-gauge) needle is mounted on a 10-cc syringe. Infiltration is the method of choice for administering local anesthesia for aspiration and incision of peritonsillar abscesses.
    • The needle is passed through the anesthetized mucosa where aspiration of the site is performed.
    • Aspiration of purulent material is diagnostic, and the material may be sent for culture.
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Contributor Information and Disclosures
Author

Benoit J Gosselin, MD, FRCSC  Associate Professor of Surgery, Dartmouth Medical School; Director, Comprehensive Head and Neck Oncology Program, Norris Cotton Cancer Center; Staff Otolaryngologist, Division of Otolaryngology-Head and Neck Surgery, Dartmouth-Hitchcock Medical Center

Benoit J Gosselin, MD, FRCSC is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society, American Medical Association, American Rhinologic Society, Canadian Medical Association, Canadian Society of Otolaryngology-Head & Neck Surgery, College of Physicians and Surgeons of Ontario, New Hampshire Medical Society, North American Skull Base Society, and Ontario Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Brian James Daley, MD, MBA, FACS, FCCP, CNSC  Professor, Associate Program Director, Department of Surgery, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine

Brian James Daley, MD, MBA, FACS, FCCP, CNSC is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Eastern Association for the Surgery of Trauma, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, and Tennessee Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Amy L Friedman, MD  Professor of Surgery, Director of Transplantation, State University of New York Upstate Medical University College of Medicine, Syracuse

Amy L Friedman, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Medical Women's Association, American Society for Artificial Internal Organs, American Society of Transplant Surgeons, American Society of Transplantation, Association for Academic Surgery, Association of Women Surgeons, International College of Surgeons, International Liver Transplantation Society, New York Academy of Sciences, Pennsylvania Medical Society, Philadelphia County Medical Society, Society of Critical Care Medicine, and Transplantation Society

Disclosure: Nothing to disclose.

Paolo Zamboni, MD  Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy

Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA  Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital

John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract

Disclosure: AMGEN Royalty Consulting; ARdelyx Ownership interest Board membership

References

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Right peritonsillar abscess. The soft palate, which is erythematous and edematous, is displaced anteriorly. The patient has a "hot potato–sounding" voice.
Pus is aspirated through a wide-bore needle from the right peritonsillar abscess. An additional incision will be made to drain any other pus pockets.
 
 
 
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