eMedicine Specialties > Emergency Medicine > Ear, Nose, & Throat

Peritonsillar Abscess: Differential Diagnoses & Workup

Author: Ninfa Mehta, MD, Staff Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center, Kings County Hospital
Coauthor(s): Mark A Silverberg, MD, FACEP, MMB, Assistant Professor, Assistant Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate at Brooklyn; A Antoine Kazzi, MD, Chair and Medical Director, Department of Emergency Medicine, American University of Beirut, Lebanon; Mazen J El-Sayed, MD, Resident, Department of Emergency Medicine, University Of Maryland Medical Center
Contributor Information and Disclosures

Updated: Mar 11, 2009

Differential Diagnoses

Dental, Infections

Other Problems to Be Considered

Peritonsillar cellulitis
Retropharyngeal abscess
Mononucleosis
Pharyngitis
Tonsillitis
Carotid aneurysm
Epiglottitis
Parapharyngeal abscess
Leukemia
Lymphoma
Tracheitis
Ludwig angina

Workup

Laboratory Studies

  • No studies are required for peritonsillar abscess, although one might consider obtaining CBC and electrolytes if the patient had significant comorbidities.
  • Monospot test/heterophile antibody, if unclear of the diagnosis 
  • Culture of fluid from needle aspiration, if local sensitivities are suggestive of an atypical resistance pattern

Imaging Studies

  • Radiography: Lateral soft tissue neck radiographs may help rule out other causes. The anteroposterior (AP) view of the neck may demonstrate distortion of soft tissue.
  • CT scan: Head and neck scan with intravenous (IV) contrast is useful if incision and drainage (I&D) is failed, if the patient cannot open his or her mouth, or if the patient is young (<7 y). A hypodense fluid collection with rim enhancement may be seen in the affected tonsil. Foreign bodies such as fish or chicken bones may also be found as an inciting factor.
  • Ultrasonography: Intraoral ultrasonography has a sensitivity of 95.2% and specificity of 78.5%. Transcutaneous ultrasonography has a sensitivity of 80% and specificity of 92.8%. This method is cost-effective and fast.

Procedures

  • Needle aspiration: Needle aspiration is used for symptom relief and is the criterion standard for diagnosis. 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 that is most fluctuant. A needle guard may be used to prevent accidental carotid artery puncture due to the tip of the needle migrating too far posteriorly. Only 0.5 cm of the needle needs to be exposed. If a needle guard is unavailable, a curved clamp can be used to expose a small portion of the needle before inserting it into the area for aspiration. Since the superior pole is the most common place for the abscess to develop, that is usually the first place aspirated if the entire tonsil looks or feels boggy. Aspiration of the middle one third and then the lower one third should then be attempted if pus is not returned from the superior pole. Also, see Drainage, Peritonsillar Abscess.
Pus is aspirated through a widebore needle from t...

Pus is aspirated through a widebore needle from the right peritonsillar abscess. An additional incision will be made to drain any other pus pockets.

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Pus is aspirated through a widebore needle from t...

Pus is aspirated through a widebore needle from the right peritonsillar abscess. An additional incision will be made to drain any other pus pockets.


  • Abscess I&D: After lidocaine with epinephrine local infiltration, a No. 11 blade scalpel may be used to incise a very large PTA, allowing the purulent drainage to flow freely as the abscess cavity decompresses. Allow the patient to hold the Yankauer catheter tip and to suction the pus, rather than swallow it.
  • Tonsillectomy: Tonsillectomy may be used for recurrent peritonsillar abscesses.

More on Peritonsillar Abscess

Overview: Peritonsillar Abscess
Differential Diagnoses & Workup: Peritonsillar Abscess
Treatment & Medication: Peritonsillar Abscess
Follow-up: Peritonsillar Abscess
Multimedia: Peritonsillar Abscess
References
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References

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  3. Herzon FS, Martin AD. Medical and surgical treatment of peritonsillar, retropharyngeal, and parapharyngeal abscesses. Curr Infect Dis Rep. May 2006;8(3):196-202. [Medline].

  4. Losanoff JE, Missavage AE. Neglected peritonsillar abscess resulting in necrotizing soft tissue infection of the neck and chest wall. Int J Clin Pract. Dec 2005;59(12):1476-8. [Medline].

  5. Ahmed K, et al. Radiology in focus: The role of ultrasound in the management of peritonsillar abscess. J Laryngol Otol. 1994;108:610-612.

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  7. Araujo Filho BC, Sakae FA, Sennes LU, Imamura R, de Menezes MR. Intraoral and transcutaneous cervical ultrasound in the differential diagnosis of peritonsillar cellulitis and abscesses. Rev Bras Otorrinolaringol (Engl Ed). May-Jun 2006;72(3):377-81. [Medline].

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  13. Kieff DA, Bhattacharyya N, Siegel NS, Salman SD. Selection of antibiotics after incision and drainage of peritonsillar abscesses. Otolaryngol Head Neck Surg. Jan 1999;120(1):57-61. [Medline].

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  16. Martin Campagne E, del Castillo Martin F, Martinez Lopez MM, Borque de Andres C, de Jose Gomez MI, Garcia de Miguel MJ. [Peritonsillar and retropharyngeal abscesses: study of 13 years]. An Pediatr (Barc). Jul 2006;65(1):32-6. [Medline].

  17. Ozbek C, Aygenc E, Tuna EU, Selcuk A, Ozdem C. Use of steroids in the treatment of peritonsillar abscess. J Laryngol Otol. Jun 2004;118(6):439-42. [Medline].

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  19. Roberts J. Emergency department considerations in the diagnosis and treatment of peritonsillar abscess. Emerg Med News. 1996;2:4-7.

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Further Reading

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Keywords

peritonsillar abscess, tonsillitis, throat abscess, head and neck infection, peritonsillar abscess treatment, peritonsillar abscess symptoms, peritonsillar space, PTA, quinsy, peritonsillar cellulitis, retropharyngeal abscess, drainage of throat abscess 

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Contributor Information and Disclosures

Author

Ninfa Mehta, MD, Staff Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center, Kings County Hospital
Ninfa Mehta, MD is a member of the following medical societies: American Association of Physicians of Indian Origin, American Medical Association, and American Medical Student Association/Foundation
Disclosure: Nothing to disclose.

Coauthor(s)

Mark A Silverberg, MD, FACEP, MMB, Assistant Professor, Assistant Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate at Brooklyn
Mark A Silverberg, MD, FACEP, MMB is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

A Antoine Kazzi, MD, Chair and Medical Director, Department of Emergency Medicine, American University of Beirut, Lebanon
A Antoine Kazzi, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Mazen J El-Sayed, MD, Resident, Department of Emergency Medicine, University Of Maryland Medical Center
Mazen J El-Sayed, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Michael Glick, DMD, Professor and Acting Chair, Department of Diagnostic Sciences, New Jersey Dental School, University of Medicine and Dentistry of New Jersey
Michael Glick, DMD is a member of the following medical societies: American Academy of Oral Medicine and American Dental Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Mark W Fourre, MD, Program Director, Department of Emergency Medicine, Maine Medical Center; Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD, Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center
Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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