Peritonsillar Abscess in Emergency Medicine

Updated: Feb 01, 2017
  • Author: Jorge Flores, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
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Overview

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, whic Right 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, whic Right 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]

A multi-center, prospective, observational case-control study by Lepelletier et al suggested that self-medication with systemic anti-inflammatory drugs may increase the risk of peritonsillar abscess. Male gender and smoking were also linked to the condition. The study compared 120 cases of peritonsillar abscess with 143 cases of sore throat without peritonsillar abscess. [7]

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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. [8] 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. [9]

Race

No racial predilection of peritonsillar abscess is noted.

Sex

The male-to-female ratio for peritonsillar abscess is considered to be equal, although the previously mentioned study by Lepelletier did suggest that male gender is a risk factor. [7]

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. [10] The younger children who get peritonsillar abscess are often immunocompromised.

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