eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Peritonsillar Abscess

Author: Itzhak Brook, MD, MSc, Professor, Department of Pediatrics, Georgetown University School of Medicine
Contributor Information and Disclosures

Updated: Jul 30, 2008

Introduction

Background

Peritonsillar abscess (PTA) is a suppurative infection of the tissues adjacent to the palatine tonsil and is the most common abscess of the head and neck region.

Pathophysiology

The development of the abscess is often gradual, with an early stage of peritonsillar cellulitis. If not properly treated, an abscess emerges. Two mechanisms have been proposed to explain the development of a collection of pus in the loose connective tissue of the supratonsillar fossa. The more common explanation is that a PTA develops from the direct spread of an inadequately treated bacterial tonsillitis. An alternative explanation is that PTA is an abscess formed in a group of salivary glands in the supratonsillar fossa, known as Weber glands. Lymphatic drainage from an infected PTA is to the ipsilateral jugulodigastric nodes. Bacterial cultures that are also adequate for the recovery of anaerobic bacteria usually yield polymicrobial aerobic and anaerobic bacteria. Group A beta-hemolytic streptococci is recovered in 25-40% of the abscesses.

Frequency

United States

The estimated incidence is 30 per 100,000 person-years in patients aged 5-59 years.1 Approximately 25-30% of patients with PTA are in the pediatric age group.

Mortality/Morbidity

The mortality rate is unknown. Mortality is often due to aspiration of a ruptured abscess or sequelae of sepsis. Morbidity stems principally from pain and dehydration. See Complications in the Follow-up section.

Race

No race predilection is known.

Sex

No sex predilection is reported.

Age

PTA most commonly occurs in the third and fourth decades of life. Pediatric cases are more common in children older than 10 years, although cases have been described in children younger than 1 year.

Clinical

History

  • Sore throat/dysphagia
    • Usually for 5-7 days
    • Not improving on antibiotics
  • Trismus
    • Pain when mouth is opened wide
    • Secondary to inflammation of internal pterygoid muscle
  • Fever
  • Drooling
  • Muffled voice
    • Also called "hot potato" voice
    • Secondary to dysfunction of the palatal muscles on the affected side, resulting in velopharyngeal insufficiency
  • Referred ear pain

Physical

  • Moderately uncomfortable appearing
  • Febrile
  • Potential respiratory distress
  • Difficulty opening mouth (trismus)
  • Oropharynx symptoms (see Media file 1)
    • Asymmetric swelling of the soft tissues is lateral and superior to the affected tonsil with displacement of the affected tonsil medially and anteriorly.
    • Fluctuant area is palpable.
    • Appearance of tonsil may be normal or may show erythema and exudates.
    • Uvula is displaced to the contralateral side.
    • Soft palate is red and swollen.
    • Involvement is bilateral in 3% of cases.
  • Halitosis
  • Cervical (jugulodigastric) adenopathy

Causes

  • A positive culture of aerobic and/or anaerobic pathogens is observed in 60-80% of aspirates.
  • Bacterial growth is often polymicrobial, including aerobic and anaerobic bacteria of oral flora origin. More than half of the aerobic (ie, Staphylococcus aureus) and anaerobic (ie, Prevotella, Porphyromonas, and Fusobacterium species) isolates can be beta-lactamase producers.
  • Aerobic bacteria implicated in peritonsillar abscess (PTA) include the following:
    • Group A beta-hemolytic Streptococcus pyogenes (most commonly isolated aerobe)
    • Staphylococcus aureus (methicillin susceptible or methicillin resistant)
    • Alpha-hemolytic streptococci
    • Coagulase-negative staphylococci
    • Streptococcus pneumoniae (penicillin susceptible or penicillin resistant)
  • Anaerobes implicated in PTA include the following:
    • Anaerobic gram-negative bacilli (eg, pigmented Prevotella and Porphyromonas species, Bacteroides species)
    • Peptostreptococcus species
    • Fusobacterium species
  • Differentiating between PTA and peritonsillar cellulitis is often difficult because the pathogenesis is similar and patients present with similar symptoms.2 Only patients with a PTA require a drainage procedure, whereas patients with either PTA or peritonsillar cellulitis are treated with antibiotics.
  • Clinical signs such as trismus and inconsistent drooling have been associated more often with PTA. No method to differentiate between the two is perfect; however, current methods include the following:
    • Observing the patient's response to 24-48 hours of intravenous antibiotics
    • Attempting needle aspiration of the site
    • Using an imaging modality such as CT scanning or ultrasonography

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

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

  2. Brodsky L, Sobie SR, Korwin D, Stanievich JF. A clinical prospective study of peritonsillar abscess in children. Laryngoscope. Jul 1988;98(7):780-3. [Medline].

  3. Patel KS, Ahmad S, O'Leary G, Michel M. The role of computed tomography in the management of peritonsillar abscess. Otolaryngol Head Neck Surg. Dec 1992;107(6 Pt 1):727-32. [Medline].

  4. Ahmed K, Jones AS, Shah K, Smethurst A. The role of ultrasound in the management of peritonsillar abscess. J Laryngol Otol. Jul 1994;108(7):610-2. [Medline].

  5. Brook I. Microbiology and management of peritonsillar, retropharyngeal, and parapharyngeal abscesses. J Oral Maxillofac Surg. Dec 2004;62(12):1545-50. [Medline].

  6. Epperly TD, Wood TC. New trends in the management of peritonsillar abscess. Am Fam Physician. Jul 1990;42(1):102-12. [Medline].

  7. Friedman NR, Mitchell RB, Pereira KD, et al. Peritonsillar abscess in early childhood. Presentation and management. Arch Otolaryngol Head Neck Surg. Jun 1997;123(6):630-2. [Medline].

  8. Gavriel H, Vaiman M, Kessler A, Eviatar E. Microbiology of peritonsillar abscess as an indication for tonsillectomy. Medicine (Baltimore). Jan 2008;87(1):33-6. [Medline].

  9. Herzon FS. Permucosal needle drainage of peritonsillar abscesses. A five-year experience. Arch Otolaryngol. Feb 1984;110(2):104-5. [Medline].

  10. Herzon FS, Nicklaus P. Pediatric peritonsillar abscess: management guidelines. Curr Probl Pediatr. Sep 1996;26(8):270-8. [Medline].

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

  12. Kew J, Ahuja A, Loftus WK, et al. Peritonsillar abscess appearance on intra-oral ultrasonography. Clin Radiol. Feb 1998;53(2):143-6. [Medline].

  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].

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

  15. Richardson KA, Birck H. Peritonsillar abscess in the pediatric population. Otolaryngol Head Neck Surg. Nov-Dec 1981;89(6):907-9. [Medline].

  16. Scott PM, Loftus WK, Kew J, et al. Diagnosis of peritonsillar infections: a prospective study of ultrasound, computerized tomography and clinical diagnosis. J Laryngol Otol. Mar 1999;113(3):229-32. [Medline].

  17. Spires JR, Owens JJ, Woodson GE, Miller RH. Treatment of peritonsillar abscess. A prospective study of aspiration vs incision and drainage. Arch Otolaryngol Head Neck Surg. Sep 1987;113(9):984-6. [Medline].

  18. Stringer SP, Schaefer SD, Close LG. A randomized trial for outpatient management of peritonsillar abscess. Arch Otolaryngol Head Neck Surg. Mar 1988;114(3):296-8. [Medline].

  19. Weinberg E, Brodsky L, Stanievich J, Volk M. Needle aspiration of peritonsillar abscess in children. Arch Otolaryngol Head Neck Surg. Feb 1993;119(2):169-72. [Medline].

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Further Reading

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Keywords

peritonsillar abscess, PTA, quinsy, palatine tonsil, peritonsillar cellulitis, PTC, Weber glands, bacterial tonsillitis, group A streptococci, trismus, "hot potato" voice, velopharyngeal insufficiency, respiratory distress, halitosis, sore throat

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Contributor Information and Disclosures

Author

Itzhak Brook, MD, MSc, Professor, Department of Pediatrics, Georgetown University School of Medicine
Itzhak Brook, MD, MSc is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, Armed Forces Infectious Diseases Society, Association of Military Surgeons of the US, Infectious Diseases Society of America, International Immunocompromised Host Society, International Society for Infectious Diseases, Medical Society of the District of Columbia, New York Academy of Sciences, Pediatric Infectious Diseases Society, Society for Ear, Nose and Throat Advances in Children, Society for Experimental Biology and Medicine, Society for Pediatric Research, Southern Medical Association, and Surgical Infection Society
Disclosure: Nothing to disclose.

Medical Editor

Ashir Kumar, MBBS, MD, FAAP, Professor, Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University; Consulting Staff, Department of Pediatrics, EW Sparrow Hospital
Ashir Kumar, MBBS, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association of Physicians of Indian Origin, American Federation for Clinical Research, American Society for Microbiology, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Joseph Domachowske, MD, Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York-Upstate Medical University
Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Phi Beta Kappa
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Consulting; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching; sanofi pasteur Grant/research funds Unrestricted research grant; sanofi pasteur  Consulting; sanofi pasteur Honoraria Speaking and teaching; Tap Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
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