Peritonsillar Abscess

A peritonsillar abscess is the accumulation of pus in the peritonsillar space that surrounds the tonsil. The same organisms responsible for common tonsillar infections— Streptococcus and Staphylococcus species and anaerobes—are also found in peritonsillar abscesses.

The typical signs and symptoms of peritonsillar abscess include fever, sore throat for 3 to 5 days, dysphagia, odynophagia, and a muffled, "hot potato" voice. Trismus is extremely common. Examination confirms asymmetric tonsils and peri-tonsillar edema and erythema. The soft palate and uvula are swollen and displaced away from the side of the abscess. It is often difficult to distinguish between abscess and peritonsillar cellulitis. If possible, it is helpful to palpate because fluctuance indicates a loculation of pus. Diagnosis is often made by clinical impression, but computed tomography (CT) can be confirmatory and useful when the diagnosis is uncertain (Fig. 19-1).

If untreated, a peritonsillar abscess may spontaneously drain, progress to involve the deep neck, or even lead to airway obstruction. The most important part of the treatment is drainage of the abscess cavity by needle aspiration, incision and drainage, or tonsillectomy. Cultures of the aspirate can be obtained, and broad-spectrum antibiotics should be started. Appropriate antibiotics include ampicillin-sulbactam (Unasyn) or clindamycin (Cleocin). Many patients present with dehydration, and parenteral fluids should be given if necessary. Analgesics should be prescribed as needed. One or two doses of IV corticosteroids may be given to decrease inflammation and pain.

Children presenting with peritonsillar abscess should be admitted to the hospital. Treatment with IV hydration and parenteral antibiotics is appropriate initially. Patients with peritonsillar cellulitis/phlegmon or early abscess often demonstrate a rapid response to treatment, whereas those with a well-formed peritonsillar abscess do not improve. Drainage is necessary in nonresponders. Abscesses in cooperative adults can be drained under local anesthesia in the emergency department (ED) or office and treated in an outpatient setting. Children usually require general anesthesia for drainage, and a tonsillectomy may also be performed. An elective tonsillectomy is often recommended for any patient with a peritonsillar abscess to prevent recurrence, especially with a history of recurrent tonsillitis, although few, if any, controlled studies support this recommendation.

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