History
The following may be noted in patients with peritonsillar abscess (PTA):
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History of recurrent episodes of pharyngotonsillitis and previous peritonsillar abscess
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History of snoring or other symptoms of obstructive sleep apnea
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Sore throat/dysphagia and neck swelling and pain - Usually for 5-7 days; not improving on antibiotics
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Trismus - Pain when mouth is opened wide; secondary to irritation and reflex spasm of the internal pterygoid muscle
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Fever
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Pooling of saliva and drooling
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Tiredness, irritability, and reduced oral intake
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Muffled voice - Also called "hot potato" voice; secondary to dysfunction of the palatal muscles on the affected side, resulting in velopharyngeal insufficiency
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Referred ear pain
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Smoking - Has been found to be a risk factor in the development of peritonsillar abscess [21]
Peritonsillar abscess may have changed its characteristics in recent years; it is affecting more older patients, has a worse and longer course, and has emerged without antecedent tonsillitis or in spite of prior adequate antibiotic therapy. [22]
Physical Examination
Physical features are as follows [23] :
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Moderately uncomfortable appearing
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Febrile
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Potential respiratory distress
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Difficulty opening mouth (trismus)
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Oropharynx symptoms (See the image below for an example of an oropharynx examination.)
Examination of the oropharynx demonstrates unilateral swelling and erythema of the left tonsil with deviation of the uvula to the contralateral side. Courtesy of Michael Altieri, MD, Medifor, Inc. Used with permission.
Oropharynx symptoms include the following:
Asymmetric swelling of the soft tissues is lateral and superior to the affected tonsil with displacement of the affected tonsil medially and anteriorly. Bilateral peritonsillar abscess is uncommon.
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.
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Halitosis
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Cervical and submandibular lymphadenopathy
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Infection: If epiglottitis or other deep neck space infection are suspected, imaging or careful examination (with the availability of an artificial airway placement) may be required.
Complications
Most patients with peritonsillar abscess recover uneventfully after abscess drainage and antibiotic therapy. However, complications can occur and the infection can spread in the upper airway mucosa, through cervical tissues, or hematogenously. [24] Complications include the following:
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Dehydration
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Upper airway spread
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Airway obstruction
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Abscess rupture and aspiration pneumonia
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Neck tissue spread (parapharyngeal and retropharyngeal abscess)
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Septic thrombophlebitis, including Lemierre syndrome
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Parotid gland abscess
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Masticator space abscess
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Hematogenous spread (Lemierre syndrome, sepsis, lung infections, endocarditis, meningitis, brain abscess, septic arthritis)
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Immunologic reaction ( reactive arthritis)
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Examination of the oropharynx demonstrates unilateral swelling and erythema of the left tonsil with deviation of the uvula to the contralateral side. Courtesy of Michael Altieri, MD, Medifor, Inc. Used with permission.
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CT scan with contrast demonstrates a 2-cm low-attenuation mass with a minimally enhancing wall in the right peritonsillar region. Associated edema, ipsilateral jugulodigastric lymphadenopathy, compression of the internal jugular vein, and deviation of the airway are present.
