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Clinical Procedures > Otolaryngologic and Dental Procedures
Drainage, Peritonsillar Abscess
Article Last Updated: Jan 24, 2008
AUTHOR AND EDITOR INFORMATION
Section 1 of 13  
Author: Jeffrey D Suh, MD, Staff Physician, Division of Head and Neck Surgery University of California Los Angeles School of Medicine
Jeffrey D Suh is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery and Phi Beta Kappa
Coauthor(s):
Joel A Sercarz, MD, Associate Professor in Residence, Division of Head and Neck Surgery, University of California Los Angeles School of Medicine; Chief of Otolaryngology-Head and Neck Surgery, Olive View-University of California Los Angeles
Editors: Prajoy P Kadkade, MD, Assistant Professor, Department of Otolaryngology and Communicative Disorders, North Shore University Hospital-Long Island Jewish Hospital System, Albert Einstein College of Medicine; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine; Luis M Lovato, MD, Assistant Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center; Gil Z Shlamovitz, MD, Assistant Professor of Emergency Medicine, University of Connecticut School of Medicine; Attending Physician, Emergency Department, Windham Community Memorial Hospital, Willimantic, CT; Attending Physician, Emergency Department, Hartford Hospital, Hartford, CT; Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Author and Editor Disclosure
Synonyms and related keywords:
peritonsillar abscess, PTA, abscess, abscesses, peritonsillar cellulitis, incision and drainage, needle aspiration, tonsil, tonsillitis, abscess drainage, peritonsillar abscess drainage, tonsillectomy, quinsy, quinsy tonsillectomy, tonsil abscess
The peritonsillar abscess (PTA) remains a common clinical entity in the emergency department and in an otolaryngology practice. The exact incidence has been estimated at 30 cases per 100,000 people per year.
PTA is rare in infants and children younger than 12 years. The mean age for this disease is 20-30 years; males and females are affected equally. PTA usually occurs near the superior pole of the palatine tonsil, in the space outside of the tonsillar capsule between the superior constrictor and the palatopharyngeus muscle.1
An untreated PTA can lead to numerous complications, including the following: - Erosion of the carotid artery
- The development of sepsis (For information on the management of sepsis, please visit Medscape's Sepsis Resource Center.)
- The development of other localized serious bacterial infections, including mediastinitis and deep neck space infections, which arise from tracking of the infection from the tonsillar fossas to the deep fascial planes of the neck with extension into the chest
The most common treatments for PTAs include the following:2, 3 - Needle aspiration: Needle aspiration can be therapeutic in itself; in some studies, up to 85% of patients were effectively treated with outpatient needle aspiration and oral antibiotics.4, 5 Aspiration can also be used to confirm the diagnosis and localize the PTA for incision and drainage.
- Incision and drainage: Success rates of the incision and drainage technique are reported in the literature as similar to or slightly higher than reported success rates of the needle aspiration technique.
- Quinsy tonsillectomy: Quinsy is an obsolete term for PTA. The quinsy tonsillectomy, then, is a tonsillectomy performed in the presence of a PTA. The different techniques of tonsillectomy are not discussed in this article.
- Absolute
- Malignancy
- Vascular malformations
- Relative
- Pediatric patient
- Difficult or uncooperative patient
Anesthesia is indicated (topical, local, or both). Such anesthesia can include combinations of the following: - Cetacaine spray
- Viscous lidocaine
- Local injection of anesthesia6
For more information on topical anesthetics, see Anesthesia, Topical. For more information on local anesthetics, see Local Anesthetic Agents, Infiltrative Administration.
Technique for anesthesia - Spray the tonsil and ipsilateral soft palate with benzocaine (eg, Cetacaine) topical spray.
- Using an 18-gauge (ga) needle on a 10-mL syringe, draw up approximately 6-10 mL of lidocaine 1% with epinephrine.
- Change to a 27-ga needle (preferably a long needle).
- Inject the mucosa overlying the fluctuant area with local anesthetic.
Injection of local anesthetic.
- Anesthesia (benzocaine spray, lidocaine 1% with 1:100,000 epinephrine)
- Syringe, 10 mL
- Needles, 18 and 27 ga
- Scalpel (Blade should be only partially uncovered/uncapped to expose only the tip of the scalpel; this avoids a deep incision.)
- Tongue retractor (sweetheart retractor pictured below) or tongue depressor
- Long curved Kelly clamp (for blunt dissection after incision with scalpel)
- Gloves
- Oral suction
- Culture swabs, if indicated
Some equipment used for the incision and drainage of a PTA.
- The patient should be sitting upright in one of the following locations:
- At the edge of a gurney
- In an ENT examination chair
Preparation
- Explain the procedure, benefits, risks, and complications to the patient and/or the patient's representative and obtain a signed informed consent.
- Ask the patient and/or the patient's representative if they would like others to be present for the procedure.
- Ensure that adequate lighting is available.
- Ask the patient to assume the preferred upright seated position.
- An oral suction system should be available to prevent aspiration of abscess contents into the patient's airway. Turn the suction system on and test for adequate suction strength.
- Using direct visualization at all times, anesthetize the suspected area of the peritonsillar abscess. The anesthetics most commonly used are local anesthetics with or without benzocaine spray. (Benzocaine spray is sometimes used alone during the needle aspiration technique.)
Incision and drainage technique - With a guarded scalpel (only part of the blade is exposed, to prevent a deep incision from being made), make a small incision above the tonsil, in the soft palate. Medial and superior incisions are safer from the standpoint of potential injury to the carotid artery.
Incision of PTA. - Using a curved Kelly clamp, enter the incision and perform gentle blunt dissection inferiorly, posteriorly, and slightly laterally. Gentle dissection in the area of fluctuance is usually sufficient to enter the abscess cavity. Once the abscess cavity is found, continue gentle dissection with the curved Kelly clamp to break up any loculations.
Blunt dissection with curved Kelly clamp.
Needle aspiration technique - Insert an 18-ga needle on a 10-mL syringe into the area of suspected PTA.
- Aspirate with the syringe while inserting it.
- If no abscess is found, slowly withdraw the needle and reinsert.
Postdrainage
- The aspirate or abscess contents can be sent to microbiology for gram stain and culture.
- Administer a single high dose of steroid, unless contraindicated.7 One option is a single dose of Dexamethasone IV (Decadron). See Pearls for more information.
- Place the patient on oral antibiotics for 5-7 days. Selected recommended antibiotics include amoxicillin plus clavulanate (Augmentin) or clindamycin.
- Airway protection should be considered for large abscesses. If the airway is in doubt, consider intubation and drainage under general anesthesia.8 Tracheostomy is rarely necessary.
- The carotid artery lies lateral and posterior to the tonsil. Take care that the incision and dissection procedure is not performed too deep or in a lateral position. Be aware of anatomic variants of the internal carotid artery (aka aberrant carotid artery). In some patients, the carotid can be much more midline and can be in danger of iatrogenic injury during needle aspiration or incision and drainage.
Axial CT scan with contrast demonstrating an aberrant left internal carotid artery. - The incision is made superior to the tonsil in the area of the soft palate. An incision in the tonsil itself causes excessive bleeding and may miss the abscess, which is located in the peritonsillar soft tissues of the soft palate.
- Although physical examination is sufficient in most cases to make the diagnosis of a PTA, consider a contrast-enhanced CT scan of the neck or an intraoral ultrasound3 to aid in the diagnosis or to evaluate for associated complications such as deep space neck abscess, especially if the patient has an ipsilateral neck mass or fluctuance.
- In some cases, simply injecting local anesthetic into the area of maximal fluctuance can localize the abscess cavity to make the incision and drainage very simple.
- Patients with a PTA usually report pain in this area of the neck.
Usual location of neck pain. - Group A streptococci9 and anaerobic10 bacteria are the 2 most common bacteria isolated from PTA cultures.11 Antibiotics used for the treatment of PTA should cover gram-positive and anaerobic bacteria.12, 13
- A single high dose of steroid prior to antibiotic therapy dramatically improves symptoms of patients with PTAs postdrainage.7
- Severe bleeding
- Aspiration of abscess contents into the patient's airway
- Pain from inadequate anesthesia
The authors and editors of eMedicine gratefully acknowledge the assistance of Lars Grimm with the literature review and referencing for this article.
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Some equipment used for the incision and drainage of a PTA. |
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Blunt dissection with curved Kelly clamp. |
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| Media file 6a:
Axial CT scan with contrast demonstrating an aberrant left internal carotid artery. |
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| Media file 6b:
Axial CT scan with contrast demonstrating a left aberrant carotid artery. |
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- Fiechtl JF, Stack LB. Images in clinical medicine. Bilateral peritonsillar abscesses. N Engl J Med. Jun 5 2008;358(23):e27. [Medline].
- Olarinde O, Choa DI. Cannula aspiration of peritonsillar abscesses. Otolaryngol Head Neck Surg. Feb 2001;124(2):172-3. [Medline].
- Johnson RF, Stewart MG. The contemporary approach to diagnosis and management of peritonsillar abscess. Curr Opin Otolaryngol Head Neck Surg. Jun 2005;13(3):157-60. [Medline].
- Ophir D, Bawnik J, Poria Y, Porat M, Marshak G. Peritonsillar abscess. A prospective evaluation of outpatient management by needle aspiration. Arch Otolaryngol Head Neck Surg. Jun 1988;114(6):661-3. [Medline].
- Herzon FS. Permucosal needle drainage of peritonsillar abscesses. A five-year experience. Arch Otolaryngol. Feb 1984;110(2):104-5. [Medline].
- Tandon S, Roe J, Lancaster J. A randomized trial of local anaesthetic in treatment of quinsy. Clin Otolaryngol Allied Sci. Oct 2004;29(5):535-7. [Medline].
- 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].
- Ono K, Hirayama C, Ishii K, Okamoto Y, Hidaka H. Emergency airway management of patients with peritonsillar abscess. J Anesth. 2004;18(1):55-8. [Medline].
- Brook I. Microbiology and management of peritonsillar, retropharyngeal, and parapharyngeal abscesses. J Oral Maxillofac Surg. Dec 2004;62(12):1545-50. [Medline].
- 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].
- Galioto NJ. Peritonsillar abscess. Am Fam Physician. Jan 15 2008;77(2):199-202. [Medline].
- Al Yaghchi C, Cruise A, Kapoor K, Singh A, Harcourt J. Out-patient management of patients with a peritonsillar abscess. Clin Otolaryngol. Feb 2008;33(1):52-5. [Medline].
- Lamkin RH, Portt J. An outpatient medical treatment protocol for peritonsillar abscess. Ear Nose Throat J. Oct 2006;85(10):658, 660. [Medline].
Drainage, Peritonsillar Abscess excerpt Article Last Updated: Jan 24, 2008
Topic originally published: Mar 29, 2007
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