OVERVIEW: What every practitioner needs to know
Are you sure your patient has peritonsillar abscess? What are the typical findings for this disease?
Classic clinical signs and symptoms of peritonsillar abscess (PTA), also known as quinsy, include fever, sore throat, muffled voice, odynophagia, asymmetry of tonsils, swelling of soft palate, and deviation of uvula. Some patients complain of ipsilateral otalgia. Bilateral PTA can present with significant trismus and can be very difficult to diagnose on clinical grounds alone.
Young children with deep neck space abscesses tend to have a more subtle presentation. They are seldom able to verbalize their symptoms or cooperate with the physical examination. Their oropharynx is frequently difficult to examine because of its small size.
Patients younger than 4 years old present more frequently with agitation, cough, drooling, lethargy, respiratory distress, rhinorrhea, and stridor and less frequently with positive physical signs on oropharyngeal examination and trismus compared with patients 4 years or older.
Physical examination can be difficult in patients with trismus or respiratory distress. Aggressive physical examination should be avoided in these cases in order to prevent catastrophic respiratory failure due to a spontaneous abscess rupture or epiglotitis. Instead, imaging (computed tomography [CT] or intraoral ultrasound) or exam by a skilled otolaryngologist under controlled conditions, with artificial airways in place will confirm the diagnosis.
What other disease/condition shares some of these symptoms?
Acute bacterial tonsillitis
Peritonsillar cellulitis (PTC), peritonsillitis
What caused this disease to develop at this time?
Oropharyngeal infections are commonly implicated as cause of PTA. The condition is most frequent among adolescents and adults, but it can occur at any age. The disease develops when oropharyngeal bacteria invade the peritonsillar space, resulting in a collection of pus between the fibrous tonsillar capsule and the superior pharyngeal constrictor muscle. The superior pole of the palatine tonsil is most commonly affected.
PTA is commonly preceded by acute tonsillitis that progresses to cellulitis, phlegmon and abscess. However, up to 20% of patients developed PTA without prior history of tonsillitis or pharyngitis, most likely as a result of obstruction of Weber’s glands. Antecedent antibiotic therapy did not prevent development of PTA according to a recent study.
History of sore throat with progression of symptoms in spite of antibiotic therapy should alert the clinician to the possibility of PTA. Worsening sore throat, dysphagia, poor oral intake, neck pain or neck mass, fever, trismus and increased irritability in young children are highly suspicious for PTA. Trismus combined with uvular swelling and deviation can aid in differentiating between PTA and PTC.
There are no genetic factors known to predispose to PTA. Adolescents, young adults and smokers are at increased risk for PTA. The diagnosis is usually established after a careful physical examination by a skilled physician. However, examination can be difficult and limited in young children and very sick patients due to trismus. Imaging studies (CT scan or intraoral ultrasound) will establish the diagnosis.
What laboratory studies should you request to help confirm the diagnosis? How should you interpret the results?
PTA is a clinical diagnosis. However, complete blood count with differential, throat culture, aerobic and anaerobic cultures and Gram stain of purulent material from the abscess aid in the diagnosis. Leukocytosis with predominance of neutrophils is a non-specific finding. Blood culture is not sensitive enough to be recommended routinely. However, we advocate for blood culture (aerobic and anaerobic) collection in toxic appearing, febrile children.
Would imaging studies be helpful? If so, which ones?
Clinical presentations of deep neck infections are often very similar and the physical examination may be difficult. Imaging studies are frequently needed to further delineate the location in children. Plain film X ray of the neck is not as helpful as computed tomography (CT) with iodinated contrast. CT has become a valuable tool in the evaluation of pediatric patients with suspected neck abscesses with a reported sensitivity of 100% as compared with 83% sensitivity for plain lateral neck radiographs.
CT provides precise and discrete information about inflammatory processes within the retropharyngeal, parapharyngeal, lateral neck, and parotid spaces. On axial CT images, the appearance of a low-attenuation homogenous area surrounded by a rim or ring of enhancement is typical of an abscess, while cellulitis is characterized by soft tissue edema and loss of fat planes. The added expense and radiation of CT is superseded by the improved diagnostic yield and sensitivity.
Intraoral ultrasound is an alternative although it requires a cooperative patient.
If you are able to confirm that the patient has peritonsillar abscess, what treatment should be initiated?
Patients in respiratory distress should be promptly stabilized by securing their airway. A skilled physician should be involved. All children with PTA should be evaluated by an otolaryngologist. Generally, treatment of PTA involves intravenous antibiotics, surgical drainage, adequate hydration, analgesia, and close clinical monitoring for complications. Parenteral antibiotics should be started as soon as the diagnosis is suspected.
The choice of surgical drainage depends on various factors. Older cooperative children, who can tolerate local anesthesia, can undergo needle aspiration by a skilled otolaryngologist in an outpatient setting. In fact needle aspiration can be performed quickly, is relatively safe, and can be both diagnostic and therapeutic. Those patients will require observation for complications of needle aspiration such as bleeding, aspiration of pus or blood. Prior to discharge, patients have to be able to take oral antibiotics and liquids and have their pain well controlled. In addition, patients should have a close medical follow up (1-2 days) in place.
In view of mixed flora that causes PTA and increasing number of beta-lactamase producing organisms, use of parenteral antibiotics active against Group A streptococcus, Staphylococcus aureus, and respiratory anaerobes is recommended. Clindamycin (25-40 mg/kg/day IV divided every 6-8 hours) or ampicilin-sulbactam (200 mg ampicillin/kg/day IV divided every 6 hours) are appropriate initial antibiotic choices. Imipenem (60-100 mg/kg/day IV divided every 6 hours) or meropenem (60 mg/kg/dose IV divided every 8 hours) are suitable, although more expensive alternatives.
Patients found to be infected with MRSA should be treated with vancomycin (60 mg/kg/day IV divided every 6 hours) or clindamycin (40 mg/kg/day IV divided every 8 hours). Clindamycin should only be used if MRSA isolate is susceptible to clindamycin, or local epidemiology supports its empiric use (clindamycin resistance < 10%). Oral linezolid is an expensive alternative for an outpatient management of documented MRSA infection. The dose depends on age and weight of the patient: children <5 years: 30 mg/kg/day PO divided every 8 hours, children 5-11 years: 20 mg/kg/ day PO divided every 12 hours, children =12 years and adolescents 600 mg PO every 12 hours.
The decision to switch to oral antibiotics is based on clinical course and appropriate when patient is afebrile and able to swallow pills and liquid. The length of antimicrobial therapy has not been well studied. In general, 14 days of antibiotics from successful drainage should be sufficient.
Oral antibiotics suitable for outpatient management of peritonsillar cellulitis (PTC) and a drained PTA include amoxicillin-clavulanic acid (45 mg/kg/day – amoxicillin component- PO divided every 12 hours, 875 mg PO given every 12 hours in adults) or clindamycin 30 mg/kg/day PO divided every 8 hours, 450 mg PO given every 8 hours in adults.
Often, the patient’s condition is within the continuum between cellulitis and abscess, and a decision to proceed to surgery is based on both the clinical situation and the CT appearance. Individualized treatment results in more successful outcomes. Different procedures are preferred in different hospitals. Some centers use incision and drainage, others needle aspiration, and others immediate “quinsy” tonsillectomy (“tonsillectomy a chaud”).
Incision and drainage in younger children is performed by otolaryngologist under general anesthesia. The procedure is performed via intraoral access, requires oral suction before abscess penetration to prevent aspiration of purulence.
Immediate (quinsy) tonsillectomy is reserved for patients who fail incision and drainage or have a history of frequent tonsillitis. Although some otolaryngologists may advocate immediate tonsillectomy, the increased operative difficulties due to acute inflammation, and the increased risk of hemorrhage make this a less attractive option.
In general pediatric patients do not tolerate local anesthesia and require general anesthesia for both procedures. Both procedures are greater than 90% effective. PTA carries a recurrence rate of 10-15%. It is therefore important to counsel the patient that the future risk of PTA is increased. Many otolaryngologists will recommend elective tonsillectomy after PTA infection is resolved.
Clinical improvement of pain and fever is observed in 24-48 hrs after antibiotic therapy and/or surgical intervention. Patients who do not improve with antibiotics alone should be evaluated for the presence of abscess and the need for surgical intervention. Patients who had an abscess drained and continue to be febrile, or in pain, should be carefully evaluated for complications such as partial drainage of the PTA, reaccumulation of pus, extension of infection to surrounding structures, or septic jugular thrombophlebitis.
What are the adverse effects associated with each treatment option?
Antibiotic therapy is safe in general. Documented side effects of antibiotic therapy include rashes, nausea, diarrhea, bone marrow suppression, Stevens-Johnson syndrome, anaphylaxis, ototoxicity and nephrotoxicity (vancomycin), AST and ALT elevation, pseudomembranous colitis, and headache.
Risks associated with needle aspiration include reaccumulation of pus, bleeding, and missed abscess.
Risks associated with incision and drainage include a need for general anesthesia, pus aspiration, bleeding, and trauma to vital structures (nerves, carotid artery).
Risks associated with quinsy tonsillectomy include a need for general anesthesia, longer hospitalization, greater pain when compared to needle aspiration or incision and drainage, bleeding, and dehydration due to poor oral intake.
What are the possible outcomes of peritonsillar abscess?
Prompt antibiotic therapy of phlegmon and surgical drainage of mature abscess along with parenteral therapy carries a good prognosis. Complications of PTA include bacteremia with sepsis, upper airway obstruction, aspiration pneumonia, suppurative thrombophlebitis of the internal jugular vein (Lemierre’s syndrome), and erosion into the carotid artery.
All patients with PTA require antibiotic therapy to clear the infection. The goal of surgical treatment is drainage of the abscess. Antibiotics alone are not always successful in the treatment of PTA. Needle aspiration is least invasive and, when successful, carries the lowest risk for complications.
What causes this disease and how frequent is it?
PTA is the most common deep infection of the head and neck. The diagnosis of PTA increases with age and is most common among adolescents and adults. However, the disease has been described in all pediatric age groups, including very young children. The estimated annual incidence of suspected PTA among adolescents was 40 per 100,000. The incidence of PTA confirmed by drainage of pus was 3 per 100,000. Both males and females are affected similarly. Although unilateral PTA is more common than bilateral PTA, either side can be affected with similar probabilities. There is no seasonality to PTA. Smokers appeared to have higher incidence of PTA according to one study.
PTA typically results from a contiguous spread of infection from acutely infected tonsil.
There is no known genetic predisposition to PTA.
How do these pathogens/genes/exposures cause the disease?
The infection typically results from extension of infection from acute tonsillitis due to streptococcal or viral infection. Occasionally, it is a complication of infectious mononucleosis. It is unclear why some people have an uncomplicated tonsillitis and some will go on to develop PTA.
Other clinical manifestations that might help with diagnosis and management
What complications might you expect from the disease or treatment of the disease?
Recurrence of PTA is estimated at 10-15%. Patients with recurrent tonsillitis and PTA should be scheduled for tonsilectomy once the infection is resolved.
Are additional laboratory studies available; even some that are not widely available?
How can peritonsillar abscess be prevented?
There are no known interventions established for prevention of PTA. Smokers are at increased risk of PTA. Smoking cessation is advised.
What is the evidence?
Marom, T, Cinamon, U, Itskoviz, D, Roth, Y. “Changing trends of peritonsillar abscess”. Am J of Otolaryngol–Head and Neck Medicine and Surgery. vol. 31. 2010. pp. 162-167. (Large and recent study included over 400 adult and pediatric patients from Israel. Retrospective chart review of patients with PTA. Includes microbiology data from drained abscesses, clinical characteristics, complications and predisposing factors.)
Millar, KR, Johnson, DW, Drummond, D, Kellner, JD. “Suspected peritonsillar abscess in children”. Pediatr Emerg Care.. vol. 23. 2007. pp. 431-8. (Retrospective-population based review of suspected and confirmed cases of PTA.)
Brook, I. “Microbiology and Management of Peritonsillar, Retropharyngeal, and Parapharyngeal Abscesses”. J Oral Maxillofac Surg.. vol. 62. 2004. pp. 1545-1550. (Review of pediatric PTA, focuses on microbiology and management.)
Goldstein, NA, Hammerschlag, MR, Feigin, RD, Cherry, JD, Demmler-Harrison, GJ, Kaplan, SL. “Peritonsillar, retropharyngeal, and parapharyngeal abscesses”. Textbook of Pediatric Infectious Diseases. 2009. pp. 177
Schwartz, RH, Long, SS, Pickering, LK, Prober, CG. “Infections related to the upper and middle airways”. Principles and Practice of Pediatric Infectious Diseases. 2008. pp. 213
Oongoing controversies regarding etiology, diagnosis, treatment
The use of adjuvant corticosteroids for treatment of suspected PTA is a significant area of controversy. Steroid use was not associated with any significant beneficial or adverse outcomes. Given that evidence in support of steroid treatment in PTA is lacking, and that potential serious side effects of steroids are known, they should not be routinely used. It is our opinion that patients with severe pain and/or airway compromise may benefit from brief steroid treatment in addition to surgical drainage.
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- OVERVIEW: What every practitioner needs to know
- Are you sure your patient has peritonsillar abscess? What are the typical findings for this disease?
- What other disease/condition shares some of these symptoms?
- What caused this disease to develop at this time?
- Would imaging studies be helpful? If so, which ones?
- If you are able to confirm that the patient has peritonsillar abscess, what treatment should be initiated?
- What are the adverse effects associated with each treatment option?
- What are the possible outcomes of peritonsillar abscess?
- What causes this disease and how frequent is it?
- How do these pathogens/genes/exposures cause the disease?
- Other clinical manifestations that might help with diagnosis and management
- What complications might you expect from the disease or treatment of the disease?
- Are additional laboratory studies available; even some that are not widely available?
- How can peritonsillar abscess be prevented?
- What is the evidence?
- Oongoing controversies regarding etiology, diagnosis, treatment