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Peritonsillar Abscess in Emergency Medicine

  • Author: Jorge Flores, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
 
Updated: May 25, 2016
 

Practice Essentials

Peritonsillar abscesses (PTAs) are common infections of the head and neck region, accounting for approximately 30% of soft tissue head and neck abscesses. With an incidence of about 1 in 10,000, PTA (see the image below) is the most common deep space infection of the head and neck that presents to the emergency department.

Right peritonsillar abscess. The soft palate, whicRight peritonsillar abscess. The soft palate, which is erythematous and edematous, is displaced anteriorly. The patient has a "hot potato–sounding" voice.

Signs and symptoms

Symptoms of PTA usually begin 3-5 days before evaluation and may include the following:

  • Fever
  • Malaise
  • Headache
  • Neck pain
  • Throat pain (more severe on the affected side; occasionally referred to the ipsilateral ear)
  • Dysphagia
  • Change in voice
  • Otalgia
  • Odynophagia

Physical findings may include the following:

  • Mild-to-moderate distress
  • Fever
  • Tachycardia
  • Dehydration
  • Drooling, salivation, or trouble handling oral secretions
  • Trismus
  • “Hot potato” or muffled voice
  • Rancid or fetid 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

See Presentation for more detail.

Diagnosis

No definitive studies are required to diagnose PTA. The following laboratory tests may be considered:

  • Basic studies, such as complete blood count, electrolytes, and C-reactive protein (if the patient has significant comorbidities)
  • Monospot test/heterophile antibody test (to rule out infectious mononucleosis if the etiology is unclear)
  • Culture of fluid from needle aspiration (to guide antibiotic selection or changes)
  • Blood cultures (if the clinical presentation is severe)

The following imaging studies may be considered:

  • Lateral soft tissue neck radiography (to help rule out other causes)
  • Intraoral ultrasonography
  • Computed tomography (CT) of the head and neck with intravenous (IV) contrast (if incision and drainage fails, if the patient cannot open his or her mouth, or if the patient is young and uncooperative)

See Workup for more detail.

Management

Initial management of PTA may include the following:

  • Transport with supplemental oxygen.
  • Attention to the ABCs (airway, breathing, and circulation)
  • If the patient’s airway is compromised, immediate endotracheal intubation or, if this cannot be accomplished, cricothyroidotomy or tracheostomy; alternatively, awake fiberoptic bronchoscopy
  • Fluid resuscitation as necessary
  • Antipyretics for elevated temperature
  • Adequate analgesia for pain

If acute surgical management of PTA is indicated, the following 3 options are available:

  • Needle aspiration
  • Incision and drainage
  • Quinsy tonsillectomy (eg, simultaneous tonsillectomy with open abscess drainage)

Additional pharmacologic therapy may include the following:

  • Empiric antibiotics
  • Adjunctive steroids

See Treatment and Medication for more detail.

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Background

Peritonsillar abscesses (PTAs) are common infections of the head and neck region; they comprise approximately 30% of soft tissue head and neck abscesses.[1] With an incidence of about 1 in 10,000, it is the most common deep space infection of the head and neck that presents to the emergency department.[2] Physicians must be aware of the typical clinical presentation and diagnostic strategies in order to quickly diagnose and appropriately treat these patients, thus preventing complications and further propagation of the infectious process.

A peritonsillar abscess is shown in the image below.

Right peritonsillar abscess. The soft palate, whicRight peritonsillar abscess. The soft palate, which is erythematous and edematous, is displaced anteriorly. The patient has a "hot potato–sounding" voice.
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Pathophysiology

The two palatine tonsils are on the lateral walls of the oropharynx, within the depression between the anterior 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 buds of endodermal cells.[3] The tonsils then grow irregularly and reach their ultimate size and shape at approximately age 6-7 years.

Each tonsil is surrounded by a capsule, a specialized portion of the intrapharyngeal aponeurosis that covers the medial portion of the tonsils and provides a path for blood vessels and nerves.[3] It is within this potential space, between the tonsil and capsule, that peritonsillar abscesses form.[4] Note that the peritonsillar space is anatomically contiguous with several deeper spaces, and infections can potentially involve the parapharyngeal and retropharyngeal spaces.[5]

Peritonsillar abscesses usually progress from tonsillitis to cellulitis and ultimately to abscess formation. 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 the tonsillar area of debris. If these glands become inflamed, local cellulitis develops. As the infection 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.[4]

Klug et al, citing evidence for peritonsillar abscess as a complication of acute tonsillitis and as a consequence of Weber gland infection, hypothesized that peritonsillar abscesses develop when bacteria infect the tonsillar mucosa and then, using the salivary duct system, spread to the peritonsillar space.[6]

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Frequency

United States

In the United States, the incidence of peritonsillar abscess has been estimated at 30 cases per 100,000 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.[7] Most infections occur during November to December and April to May, which coincide with the highest incidence rates of streptococcal pharyngitis and exudative tonsillitis.[4]

International

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

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Mortality/Morbidity

Mortality of peritonsillar abscess is unknown. Morbidity of peritonsillar abscess is due mostly to pain, cost of treatment, lost time from work and school, and complications.

Using data from the National (Nationwide) Inpatient Sample, a study by Qureshi et al found evidence that retropharyngeal abscess is occurring at an increasing rate among adult inpatients with peritonsillar abscess. According to the investigators, between 2003 and 2010 the annual rate at which retropharyngeal abscess occurred concurrently with peritonsillar abscess rose from 0.5% to 1.4% among inpatients aged 18 years or older. The study also indicated that patient age affects concurrence of the two conditions, with the likelihood that retropharyngeal abscess will complicate peritonsillar abscess increasing in patients aged 40 years or older.[8]

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, although peritonsillar abscess is most commonly seen in those aged 20-40 years.[9] The younger children who get peritonsillar abscess are often immunocompromised.

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Contributor Information and Disclosures
Author

Jorge Flores, MD Resident Physician, Department of Emergency Medicine, Kings County Hospital Center, SUNY Downstate Medical Center

Jorge Flores, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Coauthor(s)

Ninfa Mehta, MD, MPH Clinical Assistant Professor, Ultrasound Fellowship Director, Department of Emergency Medicine, Kings County Hospital, State University of New York Downstate Medical Center

Ninfa Mehta, MD, MPH is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, American Medical Student Association/Foundation, Society for Academic Emergency Medicine, American Association of Physicians of Indian Origin

Disclosure: Nothing to disclose.

Audrey J Tan, DO Staff Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center, Kings County Hospital Center

Audrey J Tan, DO is a member of the following medical societies: American College of Emergency Physicians, American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician, Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Palmetto Richland Hospital

Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, South Carolina Medical Association, Columbia Medical Society, South Carolina College of Emergency Physicians, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Chief Editor for Medscape.

Additional Contributors

Michael Glick, DMD Dean, University of Buffalo School of Dental Medicine

Michael Glick, DMD is a member of the following medical societies: American Academy of Oral Medicine, American Dental Association

Disclosure: Nothing to disclose.

Acknowledgements

Mazen J El-Sayed, MD Resident Physician, Department of Emergency Medicine, University of Maryland Medical Center

Disclosure: Nothing to disclose.

Mark W Fourre, MD Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine; Program Director, Department of Emergency Medicine, Maine Medical Center

Disclosure: Nothing to disclose.

A Antoine Kazzi, MD Deputy Chief of Staff, American University of Beirut Medical Center; Associate Professor, 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.

References
  1. Johnson RF, Stewart MG, Wright CC. An evidence-based review of the treatment of peritonsillar abscess. Otolaryngol Head Neck Surg. 2003 Mar. 128(3):332-43. [Medline].

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

  3. Steyer TE. Peritonsillar abscess: diagnosis and treatment. Am Fam Physician. 2002 Jan 1. 65(1):93-6. [Medline].

  4. Galioto NJ. Peritonsillar abscess. Am Fam Physician. 2008 Jan 15. 77(2):199-202. [Medline].

  5. Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin North Am. 2008 Jun. 41(3):459-83, vii. [Medline].

  6. Klug TE, Rusan M, Fuursted K, Ovesen T. Peritonsillar Abscess: Complication of Acute Tonsillitis or Weber's Glands Infection?. Otolaryngol Head Neck Surg. 2016 Mar 29. [Medline].

  7. Johnson RF, Stewart MG. The contemporary approach to diagnosis and management of peritonsillar abscess. Curr Opin Otolaryngol Head Neck Surg. 2005 Jun. 13(3):157-60. [Medline].

  8. Qureshi HA, Ference EH, Tan BK, et al. National Trends in Retropharyngeal Abscess among Adult Inpatients with Peritonsillar Abscess. Otolaryngol Head Neck Surg. 2015 Jan 20. [Medline].

  9. Herzon FS. Harris P. Mosher Award thesis. Peritonsillar abscess: incidence, current management practices, and a proposal for treatment guidelines. Laryngoscope. 1995 Aug. 105(8 Pt 3 Suppl 74):1-17. [Medline].

  10. Sakae FA, Imamura R, Sennes LU, Araujo Filho BC, Tsuji DH. [Microbiology of peritonsillar abscesses]. Rev Bras Otorrinolaringol (Engl Ed). 2006 Mar-Apr. 72(2):247-51. [Medline].

  11. Klug TE, Henriksen JJ, Fuursted K, Ovesen T. Significant pathogens in peritonsillar abscesses. Eur J Clin Microbiol Infect Dis. 2011 May. 30(5):619-27. [Medline].

  12. Powell EL, Powell J, Samuel JR, Wilson JA. A review of the pathogenesis of adult peritonsillar abscess: time for a re-evaluation. J Antimicrob Chemother. 2013 Sep. 68(9):1941-50. [Medline].

  13. Powell J, Wilson JA. An evidence-based review of peritonsillar abscess. Clin Otolaryngol. 2012 Apr. 37(2):136-45. [Medline].

  14. Lyon M, Blaivas M. Intraoral ultrasound in the diagnosis and treatment of suspected peritonsillar abscess in the emergency department. Acad Emerg Med. 2005 Jan. 12(1):85-8. [Medline].

  15. Costantino TG, Satz WA, Dehnkamp W, Goett H. Randomized trial comparing intraoral ultrasound to landmark-based needle aspiration in patients with suspected peritonsillar abscess. Acad Emerg Med. 2012 Jun. 19(6):626-31. [Medline].

  16. Johnson RF, Stewart MG, Wright CC. An evidence-based review of the treatment of peritonsillar abscess. Otolaryngol Head Neck Surg. 2003 Mar. 128(3):332-43. [Medline].

  17. Rahn R, Hutten-Czapski P. Quinsy (peritonsillar abscess). Can J Rural Med. 2009 Winter. 14(1):25-6. [Medline].

  18. Bovo R, Barillari MR, Martini A. Hospital discharge survey on 4,199 peritonsillar abscesses in the Veneto region: what is the risk of recurrence and complications without tonsillectomy?. Eur Arch Otorhinolaryngol. 2015 Jan 11. [Medline].

  19. Chau JK, Seikaly HR, Harris JR, Villa-Roel C, Brick C, Rowe BH. Corticosteroids in peritonsillar abscess treatment: a blinded placebo-controlled clinical trial. Laryngoscope. 2014 Jan. 124 (1):97-103. [Medline].

  20. Lee YJ, Jeong YM, Lee HS, Hwang SH. The Efficacy of Corticosteroids in the Treatment of Peritonsillar Abscess: A Meta-Analysis. Clin Exp Otorhinolaryngol. 2016 Jun. 9 (2):89-97. [Medline]. [Full Text].

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

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

  23. Aldakhail AA, Khan MI. A retrospective study of peritonsillar abscess in Riyadh Medical Complex [corrected]. Saudi Med J. 2006 Aug. 27(8):1217-21. [Medline].

  24. 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). 2006 May-Jun. 72(3):377-81. [Medline].

  25. Blokmanis A. Ultrasound in the diagnosis and management of peritonsillar abscesses. J Otolaryngol. 1994 Aug. 23(4):260-2. [Medline].

  26. Chen MM, Roman SA, Sosa JA, Judson BL. Safety of Adult Tonsillectomy: A Population-Level Analysis of 5968 Patients. JAMA Otolaryngol Head Neck Surg. 2014 Jan 30. [Medline].

  27. Garcia Callejo FJ, Nunez Gomez F, Sala Franco J, Marco Algarra J. [Management of peritonsillar infections]. An Pediatr (Barc). 2006 Jul. 65(1):37-43. [Medline].

  28. Hanna BC, McMullan R, Hall SJ. Corticosteroids and peritonsillar abscess formation in infectious mononucleosis. J Laryngol Otol. 2004 Jun. 118(6):459-61. [Medline].

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

  30. Lamkin RH, Portt J. An outpatient medical treatment protocol for peritonsillar abscess. Ear Nose Throat J. 2006 Oct. 85(10):658, 660. [Medline].

  31. Lyon M, Blaivas M. Intraoral ultrasound in the diagnosis and treatment of suspected peritonsillar abscess in the emergency department. Acad Emerg Med. 2005 Jan. 12(1):85-8. [Medline].

  32. 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). 2006 Jul. 65(1):32-6. [Medline].

  33. Melville NA. Adult tonsillectomy shown to be safe, with few complications. Medscape Medical News. 2014 Feb 4. [Full Text].

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

  35. Passy V. Pathogenesis of peritonsillar abscess. Laryngoscope. 1994 Feb. 104(2):185-90. [Medline].

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

  37. Sakaguchi M, Sato S, Asawa S, Taguchi K. Computed tomographic findings in peritonsillar abscess and cellulitis. J Laryngol Otol. 1995 May. 109(5):449-51. [Medline].

  38. Strong EB, Woodward PJ, Johnson LP. Intraoral ultrasound evaluation of peritonsillar abscess. Laryngoscope. 1995 Aug. 105(8 Pt 1):779-82. [Medline].

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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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