AUTHOR AND EDITOR INFORMATION

Section 1 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

INTRODUCTION

Section 2 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Background

Peritonsillar abscess (PTA) is a common infection of the head and neck region. Combinations of aerobic and anaerobic bacteria colonize the peritonsillar space. This potential space is bounded by the tonsillar pillars anteroposteriorly, the piriform fossa inferiorly, and the hard palate superiorly.

Pathophysiology

Peritonsillar abscess is an infection that begins superficially and progresses into the deep soft tissues. The exact mechanism of the initial abscess formation is not known. Abscesses form between the palatine tonsil and its capsule, usually at the superior pole. It is believed that these abscesses most likely arise from an acute episode of tonsillitis, which then progresses to involve the soft tissues surrounding this area. Another proposed mechanism is necrosis and pus formation in the capsular area, which then obstructs the weber glands, which then swell, and the abscess forms.

Frequency

United States

According to Herzon, peritonsillar abscess is the most common infection of the peritonsillar region.¹ In the United States, the incidence is somewhere around 30 cases per 100,000 persons per year, accounting for approximately 45,000 cases annually.

International

A higher rate due to recurrence and antibiotic resistance is reported internationally.

Mortality/Morbidity

• The death rate 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.¹ The younger children who get peritonsillar abscess often are immunocompromised.

CLINICAL

Section 3 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

History

Symptoms of peritonsillar abscess usually begin 3-5 days prior to evaluation.

• Sore throat, which may be unilateral
• Dysphagia
• Change in voice
• Headache
• Malaise
• Fever
• Neck pain
• Otalgia
• Odynophagia

Physical

Physical findings of peritonsillar abscess include the following:

• Mild/moderate distress
• Fever
• Tachycardia
• Dehydration
• Drooling, salivation, trouble handling oral secretions
• Trismus (inability or difficulty in opening the mouth)
• Hot potato/muffled voice (sounds like they are talking with hot food in their mouth)
• 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
• Exudate on the tonsil

For a CME/CE activity, see Examining the Ears, Nose, and Oral Cavity in the Older Patient.

Causes

PTAs are usually polymicrobial when the drained pus is cultured. The most common aerobic species found are Streptococcus species (especially Streptococcus pyogenes), and the most common anaerobic species found are Prevotella species and Peptostreptococcus species.² 

DIFFERENTIALS

Section 4 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Other Problems to be Considered

Peritonsillar cellulitis
Retropharyngeal abscess
Mononucleosis
Pharyngitis
Tonsillitis
Carotid aneurysm
Epiglottitis
Parapharyngeal abscess
Leukemia
Lymphoma
Tracheitis
Ludwig angina

WORKUP

Section 5 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Lab Studies

• No studies are required for peritonsillar abscess, although one might consider obtaining CBC and electrolytes if the patient had significant comorbidities.
• Monospot test/heterophile antibody, if unclear of the diagnosis 
• Culture of fluid from needle aspiration, if local sensitivities are suggestive of an atypical resistance pattern

Imaging Studies

• Radiography: Lateral soft tissue neck radiographs may help rule out other causes. The anteroposterior (AP) view of the neck may demonstrate distortion of soft tissue.
• CT scan: Head and neck scan with intravenous (IV) contrast is useful if incision and drainage (I&D) is failed, if the patient cannot open his or her mouth, or if the patient is young (<7 y). 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.
• Ultrasonography: Intraoral ultrasonography has a sensitivity of 95.2% and specificity of 78.5%. Transcutaneous ultrasonography has a sensitivity of 80% and specificity of 92.8%. This method is cost-effective and fast.

Procedures

• Needle aspiration: Needle aspiration is used for symptom relief and is the criterion standard for diagnosis. 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. Since the superior pole is the most common place for the abscess to develop, that is usually the first place aspirated if the entire tonsil looks or feels boggy. 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.
• Abscess I&D: After lidocaine with epinephrine local infiltration, a No. 11 blade scalpel may be used to incise a very large PTA, allowing the purulent drainage to flow freely as the abscess cavity decompresses. Allow the patient to hold the Yankauer catheter tip and to suction the pus, rather than swallow it.
• Tonsillectomy: Tonsillectomy may be used for recurrent peritonsillar abscesses.

TREATMENT

Section 6 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Prehospital Care

• Prehospital care includes transport with supplemental oxygen.

Emergency Department Care

• ABCs, paying attention to the patient's airway, should be evaluated. If the patient's airway is compromised, he or she needs immediate endotracheal intubation. If this cannot be completed, then a cricothyroidotomy or a tracheotomy may need to be performed.
• These patients are often dehydrated because of their avoidance of food and liquid and will need fluid resuscitation.
• Antipyretics should be administered for elevated temperature, and adequate analgesia should be provided for pain.
• Needle aspiration should be performed to drain the abscess and should provide moderate pain relief. Larger abscesses may require incision and drainage, and if the emergency provider is not comfortable with this procedure, an ENT may be consulted. See Drainage, Peritonsillar Abscess.
• Antibiotics for empirical treatment of a streptococcal infection should be administered. Steroids have been shown in one study to decrease the number of in-hospital days.³
• Patients can be managed on an outpatient basis unless they show signs of toxicity, sepsis, airway compromise, or complications. 

Consultations

Otolaryngologist, anesthesiologist for difficult airway management

MEDICATION

Section 7 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Antibiotics are the main component of therapy. Along with drainage of the abscess, antibiotics usually suffice to resolve PTA. Begin antibiotic therapy prior to needle aspiration and report of culture results. Because of streptococcal resistance of more than 30% and infection with mixed bacterial flora, many practitioners recommend combination therapy of a penicillin and metronidazole (98% sensitivity). Some physicians still use only penicillin initially. Penicillin resistance is reported in 11-65% of patients. In those patients allergic to penicillin, a good choice would be clindamycin. Analgesics and throat washes are recommended. Some physicians report using adjunctive steroids to decrease edema and pain.

Drug Category: Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

FOLLOW-UP

Section 8 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Further Inpatient Care

• Observation, imaging studies, airway management, and intravenous hydration may be required.
• Other methods of operative management strategy may be indicated and should be performed by an otolaryngologist.
• • Incision and drainage formerly was the treatment of choice; however, great care must be taken in suctioning the purulent material to avoid aspiration, which may lead to pneumonitis and/or pneumonia. When performing incision and drainage be sure to have a small blade or use a cross clamp to have only a small (approximately 0.5 cm) of the blade exposed while making the incision. This will prevent any exposure of the needle to the carotid artery.
  • Emergent tonsillectomy came under criticism because studies of the procedure demonstrated that desired outcomes did not occur as rapidly as supporters had predicted.
  • • Costs were increased considerably.
    • Bleeding complications were higher (1-7%).
    • Less invasive and equally effective alternatives are now available in uncomplicated cases.
    • Emergent tonsillectomy is used to treat patients with a history of 3 or more PTAs.
    • Recurrence obviates the need for a second hospitalization for interval tonsillectomy after incision and drainage. Whether recurrence is an indication for tonsillectomy remains unclear.
  • To prevent recurrence, interval tonsillectomy may be considered 3-4 weeks after disappearance of edema and symptoms. The value of such a strategy is somewhat controversial. Tonsillectomy reduces the need for admission for recurrences of PTA; however, that need is rare since most PTAs now are treated percutaneously and on an outpatient basis.

Further Outpatient Care

• If outpatient care is used, the patient can be discharged (after needle aspiration treatment) on an appropriate regimen of antibiotics and pain medications.
• Relative indications for elective tonsillectomy can be identified in almost a third of all patients who present with PTA (eg, recurrent tonsillitis).

Complications

Complications of peritonsillar abscess may include the following:

• Necrotizing soft tissue infection of the neck and chest wall⁴
• Recurrence
• Aspiration, which may lead to pneumonia or pneumonitis
• Cervical abscess
• Mediastinitis
• Meningitis
• Sepsis
• Cerebral abscess
• Jugular vein thrombosis
• Carotid artery rupture/necrosis
• Carotid artery injury (from I&D or needle aspiration) 

Prognosis

• Uncomplicated, treated peritonsillar abscess has a resolution rate of 94%. In the United States, the recurrence rate is 10%, although this rate jumps to 15% internationally.

Patient Education

• For excellent patient education resources, visit eMedicine's Ear, Nose, and Throat Center. Also, see eMedicine's patient education articles Peritonsillar Abscess, Tonsillitis, and Antibiotics.

REFERENCES

Section 9 of 9

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

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2. Sakae FA, Imamura R, Sennes LU, Araújo Filho BC, Tsuji DH. [Microbiology of peritonsillar abscesses]. Rev Bras Otorrinolaringol (Engl Ed). Mar-Apr 2006;72(2):247-51. [Medline].
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16. Martín Campagne E, del Castillo Martín F, Martínez López MM, Borque de Andrés C, de José Gómez MI, García de Miguel MJ. [Peritonsillar and retropharyngeal abscesses: study of 13 years]. An Pediatr (Barc). Jul 2006;65(1):32-6. [Medline].
17. Ozbek C, Aygenc E, Tuna EU, Selcuk A, Ozdem C. Use of steroids in the treatment of peritonsillar abscess. J Laryngol Otol. Jun 2004;118(6):439-42. [Medline].
18. Passy V. Pathogenesis of peritonsillar abscess. Laryngoscope. Feb 1994;104(2):185-90. [Medline].
19. Roberts J. Emergency department considerations in the diagnosis and treatment of peritonsillar abscess. Emerg Med News. 1996;2:4-7.
20. Sakaguchi M, Sato S, Asawa S, Taguchi K. Computed tomographic findings in peritonsillar abscess and cellulitis. J Laryngol Otol. May 1995;109(5):449-51. [Medline].
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Article Last Updated: Nov 4, 2008