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Symptoms: Sore Throat, Fever, Drooling, Hoarseness

Wiler, Jennifer L. MD, MBA

doi: 10.1097/01.EEM.0000349233.39762.5d
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Dr. Wiler is the assistant chief of clinical operations in the department of emergency medicine and the medical director of the ED Observation Unit at Washington University and Barnes-Jewish Hospital in St. Louis.

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A 26-year-old man with no past medical history complains of a severe sore throat for five days. He had a temperature of 101°F the previous night, chills, and decreased oral intake.

On presentation, he is drooling, and has right ear pain, a “hoarse voice,” and difficulty opening his mouth. He denies shortness of breath, neck stiffness, and vision problems.

On examination, the patient had 2 cm of trismus, and a limited view of the pharynx revealed a bulging right peritonsillar area with mild uvular deviation. His CT scan is shown. What is the diagnosis and recommended treatment?

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Diagnosis: Peritonsillar Abscess

Peritonsillar abscess (PTA), also known as quinsy, is the most common deep neck space infection in young adults (15–30 years old) and children. It results from suppurative extension of acute tonsillitis into the peritonsillar space. PTA typically begins as pharyngitis or tonsillitis. (Curr Infect Dis Rep 2006;8[3]:196.) When inflamed, cellulitis can develop and subsequently lead to local duct obstruction and abscess formation, explaining why some patients develop PTA despite tonsillectomy. Smoking and periodontal disease are also thought to be risk factors.

Patients often give a history of fever, malaise, sore throat (usually worse on affected side), odynophagia, dysphagia, and ipsilateral otalgia. They may be ill or appear toxic and febrile. Oropharyngeal exam will reveal an erythematous, tense swollen mass of the soft palate just superior to the affected swollen tonsil. The uvula may be deviated away from the tonsil secondary to local mass effect. Patients with significant PTA typically have trismus, drooling (because of mechanical obstruction or dysphagia), a muffled “hot potato” voice, fetor breath, and local cervical lymphadenopathy or unilateral tender lymphadenitis.

Hemorrhage, acute airway obstruction, aspiration, or local spread of infection into the mediastinum, deep neck space, carotid sheath, or vessels are known life-threatening complications of PTA, and should be treated quickly. Significant airway obstruction requires emergent management.

Differentiating between PTA and peritonsillar cellulitis can be difficult, but radiologic studies and needle aspiration can confirm PTA (false negatives: 12%–24%, especially in early abscess formation). Ultrasound, CT scan with contrast, or MRI can help differentiate cellulitis from PTA and identify any local abscess spread. MRI is the preferred modality if extension into the carotid sheath or vessels is suspected. The differential diagnosis of PTA includes tonsillitis, peritonsillar cellulitis, lymphoma, infectious mononeucleosis, retropharyngeal abscess or cellulitis, retromolar abscess, epiglottitis, or internal carotid artery aneurysm. Treatment of PTA includes antibiotics, hydration, analgesia, and abscess drainage. Patients, especially children, may require operative evaluation and management if potential airway compromise exists.

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Nearly 50 percent of peritonsillar abscesses are polymicrobial, and penicillin monotherapy is no longer recommended. (Semin Respir Infect 2002;17[3]:195.) Group A streptococcus, Staphylococcus aureus, Haemophilus influenza, and oral anaerobes are most commonly isolated. (Am Fam Physician 2008;77[2]:199.) Broad-spectrum empiric antibiotic coverage including clindamycin, cephalosporins, ampicillin/sulbactam, and amoxicillin/ clavulanate are reasonable choices. Vancomycin should be added if MRSA is suspected.

Drainage of the abscess and antibiotics cure 90 percent of cases (Curr Infect Dis Rep 2006;8[3]:196), and drainage can be performed by needle aspiration, incision and drainage, or tonsillectomy, with no difference in outcome between I&D and needle aspiration alone. (Otolaryngol Head Neck Surg 2003;128[3]:332; Laryngoscope 1995;105(S3):1.)

Needle aspiration or I&D should be performed only in cooperative patients who do not have significant trismus. Procedural sedation may be useful, but protect against airway disasters, and don't over-sedate. The patient should sit upright, and an assistant can increase visualization by lateral manipulation of the lip and cheek. A “bite block” of taped tongue depressors may help with visualization by separating the upper and lower teeth. (See photograph.)

Identify the area of maximal fluctuance, and anesthetize with local infiltration using a small-gauge needle. Pretreatment with a topical anesthetic may be helpful. Advancing a long 18- or 20-gauge needle no deeper than 1 cm into the superior pole of the peritonsillar space is recommended. Ultrasound also may be useful. (Acad Emerg Med 2005;12[1]:85.) If no pus is retrieved, access the inferior pole. If pus is retrieved, aspirate fully (usually 2 to 6 ml). (Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine, 4th Ed. Philadelphia: W.B. Saunders; 2004.) Take care to advance the needle sagittally, not laterally, because the carotid artery is 2.5 cm behind and lateral to the tonsil. The cure rate is 94 percent; recurrence after aspiration is about 10 percent. A microbiologic culture of the pus will help tailor antibiotics.

If pus is retrieved, some recommend incision and drainage at the site of pus retrieval using a puncture technique with an 11 blade. The patient can then be instructed to evacuate the expressed pus using an oral suction tip. Having the patient swish and spit saline after the procedure will remove blood and pus from the mouth. Bleeding will occur, and patients should be observed to ensure that it resolves. The patient should be able to tolerate adequate oral intake before discharge.

Before antibiotics, the risk of death associated with PTA was more than 50 percent and thought to be secondary to infection in the parapharyngeal space. The risk of developing a second PTA is approximately 10 percent to 15 percent. (Am Fam Physician 2008; 77[2]:199; J Oral Maxillofac Surg 2004; 62[12]):1545.) For patients with a history of recurrent tonsillitis, the recurrence rate is as high as 40 percent.

This patient's CT verified a large right side and smaller left side PTA. A bedside incision and drainage was performed, and empiric antibiotics were initiated. The patient had an uneventful recovery, and has not returned to the ED.

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