Overview
Definition:
A peritonsillar abscess (PTA) is a localized collection of pus in the peritonsillar space, which is the space between the tonsillar capsule and the superior constrictor muscle of the pharynx
It is the most common deep neck space infection in children and adolescents.
Epidemiology:
While less common in younger children (<10 years) compared to adolescents and young adults, PTA can occur at any age
It typically arises as a complication of acute tonsillitis or pharyngitis, often caused by Group A Streptococcus or anaerobic bacteria
Recurrence is possible.
Clinical Significance:
PTA can lead to significant morbidity if not promptly diagnosed and treated
Potential complications include airway compromise, deep neck space infections (e.g., retropharyngeal, parapharyngeal abscesses), sepsis, and aspiration pneumonia
Effective management is crucial for patient recovery and preventing these serious sequelae.
Clinical Presentation
Symptoms:
Severe unilateral sore throat, often sudden in onset
Pain that is severe and often referred to the ear (otalgia)
Trismus (difficulty opening the mouth)
Muffled or "hot potato" voice
Difficulty swallowing (dysphagia) and drooling
Fever
Malaise
Neck stiffness or pain.
Signs:
Asymmetric tonsillar swelling with characteristic bulging of the soft palate and uvula towards the affected side
"Quinsy" unilateral tonsillar enlargement
Erythema of the tonsil and surrounding mucosa
Edema of the uvula, often deviated away from the affected side
Purulent exudate may be present
Palpable, tender cervical lymphadenopathy
Trismus noted on oral examination.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on the characteristic history and physical examination findings
Confirmation may be achieved with imaging if the diagnosis is uncertain or to assess the extent of the abscess.
Diagnostic Approach
History Taking:
Detailed history of sore throat, onset, severity, and unilateral nature
Previous episodes of tonsillitis or PTA
History of immunodeficiency
Recent upper respiratory infections
Medications used for symptoms
Allergies.
Physical Examination:
Careful examination of the oropharynx, noting tonsillar symmetry, erythema, edema, and uvular deviation
Assessment of the degree of trismus
Palpation of cervical lymph nodes for tenderness and size
Assessment of airway patency
Vital signs, including temperature and respiratory rate.
Investigations:
Generally, laboratory investigations are not essential for diagnosis but may be performed for supportive care
Complete Blood Count (CBC) may show leukocytosis
Cultures of exudate or throat swab are rarely helpful for PTA itself
Imaging: Ultrasound of the neck can be useful for confirming the presence and size of the abscess
CT scan of the neck with contrast is indicated if there is suspicion of deeper neck space involvement or if diagnosis is unclear.
Differential Diagnosis:
Severe unilateral tonsillitis
Retropharyngeal abscess
Parapharyngeal abscess
Epiglottitis
Diphtheria
Foreign body in the pharynx
Torticollis
Benign or malignant tumors of the tonsil or pharynx.
Management
Initial Management:
Airway assessment and maintenance are paramount
Intravenous fluid administration for hydration
Analgesics (e.g., paracetamol, ibuprofen) and antipyretics for pain and fever control
Prompt consultation with ENT specialists.
Medical Management:
Antibiotics are an essential adjunct to drainage, targeting common pathogens
Empiric broad-spectrum antibiotics should be initiated intravenously
Options include amoxicillin-clavulanate, clindamycin, or a combination of a penicillin (e.g., ampicillin-sulbactam) with metronidazole
Duration typically 7-10 days
Oral antibiotics may be used for mild cases or as a transition from IV therapy
Dosing in children should be age and weight-appropriate
Examples: Amoxicillin-clavulanate 45 mg/kg/day divided BID (max 875mg/dose) IV or PO
Clindamycin 10 mg/kg/day divided TID or QID (max 1800mg/day) IV or PO.
Surgical Management:
Peritonsillar abscess drainage is the definitive treatment
This can be achieved by needle aspiration or incision and drainage (I&D)
The procedure is typically performed under local anesthesia with or without sedation, or under general anesthesia in younger children or those with severe trismus/airway concerns
A small bore needle can aspirate pus
if pus is obtained, a larger bore needle or scalpel may be used for more thorough drainage
The goal is to evacuate all purulent material
Following drainage, oral antibiotics are continued.
Supportive Care:
Adequate pain control is crucial
Encourage fluid intake
Monitor for airway compromise and signs of spreading infection
Nasogastric feeding may be required for severe dysphagia
Close observation for recurrence or complications.
Complications
Early Complications:
Airway obstruction
Sepsis
Necrotizing fasciitis
Rupture of the abscess with aspiration
Dehydration
Spread to deeper neck spaces (retropharyngeal, parapharyngeal, mediastinitis).
Late Complications:
Recurrent peritonsillar abscess
Scarring and chronic pharyngeal pain
Velopharyngeal insufficiency (rare).
Prevention Strategies:
Prompt and adequate treatment of acute tonsillitis and pharyngitis
Educating patients and parents about early symptoms of PTA
Ensuring complete antibiotic courses for pharyngeal infections.
Prognosis
Factors Affecting Prognosis:
Timeliness of diagnosis and treatment
Adequacy of drainage
Virulence of the pathogen
Underlying immune status of the patient
Development of complications.
Outcomes:
With prompt and appropriate management (drainage and antibiotics), the prognosis is generally excellent
Most children recover fully without long-term sequelae
Recurrence rates are variable but can be reduced by tonsillectomy in select cases after resolution of the acute episode.
Follow Up:
Follow-up is recommended within 24-48 hours after drainage to ensure adequate healing and assess for complications
A follow-up appointment 1-2 weeks later to confirm resolution is also advisable
Discuss elective tonsillectomy with the family if recurrent episodes of tonsillitis or PTA occur, typically performed 4-6 weeks after the abscess has resolved.
Key Points
Exam Focus:
The cornerstone of PTA management is drainage, not antibiotics alone
Trismus and uvular deviation are classic signs
Airway is the priority
Broad-spectrum antibiotics are crucial adjuncts
Consider tonsillectomy for recurrent cases.
Clinical Pearls:
Always suspect PTA in a child with severe unilateral sore throat and trismus
Do not be afraid to needle aspirate if you suspect an abscess
If pus is encountered, complete drainage is essential
If drainage is inadequate or uncertain, CT is indicated
Be aware of potential airway compromise, especially in younger children.
Common Mistakes:
Treating PTA with antibiotics alone without drainage
Delaying drainage due to fear or uncertainty, leading to airway compromise or spread of infection
Inadequate drainage
Failing to consider other deep neck space infections.