Professional Documents
Culture Documents
Diagnosis and Treatment of Peritonsillar Abscess
Diagnosis and Treatment of Peritonsillar Abscess
net/publication/45088573
CITATIONS READS
0 777
1 author:
Karin Blomgren
Helsinki University Central Hospital
51 PUBLICATIONS 724 CITATIONS
SEE PROFILE
Some of the authors of this publication are also working on these related projects:
All content following this page was uploaded by Karin Blomgren on 21 June 2014.
Peritonsillar Abscess:
Diagnosis and Treatment
TERRENCE E. STEYER, M.D., University of Michigan Medical School, Ann Arbor, Michigan
Peritonsillar abscess, the most common deep infection of the head and neck that
occurs in adults, is typically formed by a combination of aerobic and anaerobic bac-
teria. The presenting symptoms include fever, throat pain, and trismus. Ultra-
sonography and computed tomographic scanning are useful in confirming a diag-
nosis. Needle aspiration remains the gold standard for diagnosis and treatment of
peritonsillar abscess. After performing aspiration, appropriate antibiotic therapy
(including penicillin, clindamycin, cephalosporins, or metronidazole) must be initi-
ated. In advanced cases, incision and drainage or immediate tonsillectomy may be
required. (Am Fam Physician 2002;65:93-6. Copyright© 2002 American Academy of
Family Physicians.)
P
Members of various eritonsillar abscess is the most
medical faculties common deep infection of the Epidemiology
develop articles for
“Practical Therapeu-
head and neck that occurs in Peritonsillar abscess is most common in
tics.” This article is one adults. This infection begins as a persons 20 to 40 years of age. Young children
in a series coordinated superficial infection and pro- are seldom affected unless they are immuno-
by the Department of gresses into tonsillar cellulitis. A peritonsillar compromised, but the infection can cause
Family Medicine at the abscess forms at the most advanced stage. significant airway obstruction in children.1,2
University of Michigan
Medical School, Ann
Early diagnosis of the abscess allows appro- This infection affects males and females
Arbor. Guest editor of priate treatment to begin before the abscess equally. Evidence shows that chronic tonsilli-
the series is Barbara spreads into the surrounding anatomic struc- tis or multiple trials of oral antibiotics for
S. Apgar, M.D., M.S., tures. A family physician who has appropriate acute tonsillitis may predispose persons to the
who is also an associ- training can diagnose and treat the majority development of a peritonsillar abscess.3
ate editor of AFP.
of patients with peritonsillar abscess.
Anatomy
The normal anatomy of the palatine tonsils
and their surrounding tissues is depicted in
Figure 1. The two tonsillar pillars define the
palatine tonsils anteriorly and posteriorly.
The glossopalatine and the pharyngopalatine
muscles are the major muscles of the anterior
and posterior pillars, respectively. The tonsil
Platoglossal arch
lays in the depression between the palatoglos-
. sal and the palatopharyngeal arches.4
. . Uvula During the embryonic stage, the tonsils
. arise from the second pharyngeal pouch as
Palatine tonsil
ILLUSTRATIONS BY RENEE L. CANNON
intrapharyngeal aponeurosis that covers the medial por- FIGURE 2. Contralateral deviation of uvula with tonsillar
tion of the tonsils and provides a path for blood vessels edema.
and nerves through its fibers.6
Peritonsillar abscesses form in the area between the pterygoid muscle.1 A distinguishing feature on physical
palatine tonsil and its capsule. If the abscess progresses, it examination is the inferior medial displacement of the
can involve the surrounding anatomy, including the mas- infected tonsil with a contralateral deviation of the uvula
seter muscles and the pterygoid muscle. If severe, the (Figure 2).3 In addition, many patients will have a thick-
infection can also penetrate the carotid sheath. ened, muffled voice often described as having a “hot
potato” quality. The most common findings from the his-
Etiology tory and physical examination are summarized in Table 2.
The most common organisms associated with periton- Table 3 outlines the differential diagnosis of peritonsillar
sillar abscess are listed in Table 1. Streptococcus pyogenes abscess. Peritonsillar cellulitis is present when the area
(group A beta-hemolytic streptococcus) is the most com- between the tonsil and its capsule is erythematous but
mon aerobic organism associated with peritonsillar lacks pus. The presence of mononucleosis can be deter-
abscess. The most common anaerobic organism is mined by obtaining a complete blood count and a hetero-
Fusobacterium. For most abscesses, a mixed profile of both phile screen. During the physical examination, the physi-
aerobic and anaerobic organisms cause the infection.7-9 cian should perform a thorough intraoral inspection to
rule out an infection of the salivary glands, teeth, and mas-
Diagnosis toid bone, as well as neoplasms, cervical adenitis, and
The most important information to obtain during the aneurysm of the internal carotid artery.
patient’s history is the location of the pain in the throat, A thorough history and physical examination can often
which suggests the location of the abscess. A thorough his- determine a diagnosis of peritonsillar abscess, but radio-
tory should determine if the patient has a fever, has diffi- logic tests may be helpful in differentiating peritonsillar
culty swallowing or has possibly ingested foreign objects. abscess from other diagnoses. Ultrasonography is the eas-
During the physical examination, trismus (inability or dif- iest and most useful tool. The ultrasound can be obtained
ficulty in opening the mouth) is often present because of transcutaneously by placing the transducer over the sub-
inflammation of the pharyngomaxillary space and mandibular gland and scanning the entire tonsillar area.
If there is a peritonsillar abscess, the abscess formation will
be demonstrated as an echo-free cavity with an irregular,
TABLE 1 well-defined circumference.10 The ultrasound can also be
Common Organisms Associated performed intraorally by placing the patient in a sitting posi-
with Peritonsillar Abscess tion. With the use of a tongue blade, the probe can be used
to scan the tonsils for echo-free areas. The presence of tris-
Aerobic Anaerobic mus may limit the ability to use intraoral sonography.11,12
Streptococcus pyogenes Fusobacterium The use of computed tomographic (CT) scanning may
Staphylococcus aureus Peptostreptococcus also be helpful in identifying an abscess formation. The CT
Haemophilus influenzae Prevotella scan should be obtained with contrast to allow for optimal
Neisseria species Bacteroides viewing of the abscess. An area of low attenuation on a con-
trast-enhanced CT scan is suggestive of abscess formation.
NEEDLE ASPIRATION
The gold standard for diagnosis of peritonsillar abscess
remains the collection of pus from the abscess through
needle aspiration. To obtain this sample, the area should be FIGURE 3. Needle aspiration of peritonsillar abscess.
anesthetized with 0.5 percent benzalkonium (Cetacaine
spray) followed by a gargle of 2 percent lidocaine (Xylo-
caine) with epinephrine. A no. 18-gauge spinal needle to remove the abscessed material. Individualized treatment
attached to a 10-mL syringe can be used to obtain mater- modalities will result in more successful outcomes.
ial from the suspected abscess. Figure 3 illustrates this pro- The choice of antibiotics is highly dependent on both
cedure being performed. The fluid obtained should be sent the gram stain and culture of the fluid obtained from the
to the laboratory for gram stain and culture to determine needle aspiration. Penicillin used to be the antibiotic of
the appropriate treatment regimen. choice for the treatment of peritonsillar abscess, but in
A needle aspiration of a peritonsillar abscess should recent years the emergence of beta-lactamase-producing
only be performed by properly trained physicians. Com- organisms has required a change in antibiotic choice.15
plications of performing the aspiration can include aspi- Results of studies16,17 suggest that 500 mg of clindamycin
ration of pus and blood, and hemorrhage. If the abscess is administered twice daily or a second- or third-generation
located in the distal part of the tonsil, puncture of the oral cephalosporin be used instead of penicillin.
carotid artery can occur. Another study1 recommends using penicillin as the
first-line agent, and, if there is no response within the first
Treatment 24 hours, adding 500 mg of metronidazole administered
The treatment of peritonsillar abscess requires both the twice daily to the regimen. All specimens should be exam-
selection of appropriate antibiotics and the best procedure ined by culture for antibiotic sensitivity to ensure appro-
priate antibiotic coverage.
Three main surgical procedures are available for the
TABLE 3 treatment of peritonsillar abscess: needle aspiration, inci-
Differential Diagnosis of Peritonsillar Abscess sion and drainage, and immediate tonsillectomy. Three
recent studies have compared needle aspiration with inci-
Peritonsillar cellulitis Cervical adenitis
sion and drainage for the treatment of peritonsillar
Tonsillar abscess Dental infections abscess.16-18
Mononucleosis Salivary gland infection In one study,16 52 consecutive patients who had a posi-
Foreign body aspiration Mastoid infection tive needle aspiration of a peritonsillar abscess were ran-
Neoplasms (lymphoma, Aneurysm of internal carotid artery domized into two groups comparing needle aspiration
leukemia) alone with incision and drainage.8 There were no signifi-
cant differences between the two groups in duration of