Peritonsillar Abscess in Emergency Medicine 

  • Author: Audrey J Tan, DO; Chief Editor: Pamela L Dyne, MD   more...
 
Updated: Apr 30, 2012
 

Background

Peritonsillar abscesses (PTAs) are common infections of the head and neck region and comprise approximately 30% of soft tissue head and neck abscesses.[1] Physicians must be aware of the typical clinical presentation and diagnostic strategies in order to quickly diagnose 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, 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 2 palatine tonsils are on the lateral walls of the oropharynx in 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.[2] 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.[2] It is within this potential space between the tonsil and capsule that peritonsillar abscesses form.[3] Note that the peritonsillar space is anatomically contiguous with several deeper spaces, and infections can potentially involve the parapharyngeal and retropharyngeal spaces.[4]

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.[3]

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Epidemiology

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.[5] Most infections occur during November to December and April to May, which coincide with the highest 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 from work 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, although peritonsillar abscess is most commonly seen in those aged 20-40 years.[6] The younger children who get peritonsillar abscess are often immunocompromised.

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Contributor Information and Disclosures
Author

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 and American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Ninfa Mehta, MD  Fellowship Director in Ultrasound Division, Department of Emergency Medicine, Kings County Hospital, State University of New York Downstate Medical Center

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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 and American Dental 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

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.

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, University of California, Los Angeles, David Geffen School of Medicine; 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.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, A Antoine Kazzi, MD, and Mazen J El-Sayed, MD, to the development and writing of this article.

References

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  13. 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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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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