Peritonsillar Abscess in Emergency Medicine Workup

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

Laboratory Studies

No definitive studies are required for the diagnosis of peritonsillar abscess, although one might consider obtaining CBC count and electrolyte evaluations if the patient had significant comorbidities.

Monospot test/heterophile antibody test can be performed to rule out infectious mononucleosis if the etiology is unclear.

Culture of fluid from needle aspiration may be performed.

Blood cultures may be indicated if the clinical presentation is severe.

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Imaging Studies

Lateral soft tissue neck radiographs may help rule out other causes. The anteroposterior (AP) view of the neck may demonstrate distortion of soft tissue.

Intraoral ultrasonography (US) has a sensitivity of 95.2% and specificity of 78.5%. This method is cost-effective and fast, although it does require a cooperative patient. A recent study carried out at an academic level I emergency department included 43 patients who received intraoral US for suspected peritonsillar abscess. Thirty-five were diagnosed with an abscess on US, and these patients subsequently received needle aspiration using US guidance. There was one false positive, but no patients returned unexpectedly after drainage, and, on reexamination, there was no evidence of persistent or recurrent peritonsillar abscess or cellulitis. This study supports the use of US for both the diagnosis and treatment of peritonsillar abscesses.[9] Prior studies of US use have shown similar successful results.

Head and neck CT scanning with intravenous (IV) contrast is useful if incision and drainage fails, if the patient cannot open his or her mouth, or if the patient is young (< 7 y) and uncooperative. 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.

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Procedures

Three options are available for acute surgical management of peritonsillar abscess: needle aspiration, incision and drainage, and quinsy tonsillectomy (eg, simultaneous tonsillectomy with open abscess drainage).

A systematic review by Johnson et al attempted to determine the best technique for acute surgical management. Forty-two articles were analyzed. Five level I clinical studies indicated that all 3 techniques were equally effective for initial management.[10]

Needle aspiration

The main advantage of needle aspiration is ease of the procedure, decreased pain for the patient, and cost-effectiveness.[5, 10]

The patient should be sitting upright.

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.

Aspirate at the superior pole initially, as this is the most common place for abscess development. 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 wide-bore needle from tPus is aspirated through a wide-bore needle from the right peritonsillar abscess. An additional incision will be made to drain any other pus pockets.

Abscess incision and drainage [11]

The patient should be sitting upright with a pan available to spit out any blood or pus.

A tongue depressor is used to retract the tongue.

After local infiltration with lidocaine with epinephrine, a No. 11 blade scalpel is used to make a small incision 0.5 cm long and no more than 1 cm deep. Be certain that the incision is not extended laterally as the carotid artery lies in that vicinity.

Use a small hemostat to probe the abscess and release the pus.

To prevent the risk of aspiration, allow the patient to hold the Yankauer catheter tip and to suction the pus.

Tonsillectomy

No clear evidence indicates that routine elective tonsillectomy is indicated to prevent future peritonsillar abscesses. However, if the patient has had multiple recurrent episodes of peritonsillar abscessor has other clear indications such as sleep-disordered breathing, elective tonsillectomy should be considered.[5]

Additionally, if general anesthesia is required because of the patient's age or lack of cooperation, tonsillectomy should be considered, as the complication rate is low and although the data do not support this, consideration for the most definitive procedure should be made.[5, 10]

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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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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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