Group 4 Peritosillar abscess

A peritonsillar abscess forms in the tissues of the throat next to one of the tonsils. An abscess is a collection of pus that forms near an area of infected skin or other soft tissue. The abscess can cause pain, swelling, and, if severe, blockage of the throat. If the throat is blocked, swallowing, speaking, and even breathing become difficult. Causes of a Peritonsillar Abscess A peritonsillar abscess is most often a complication of tonsillitis. The bacteria involved are similar to those that cause strep throat. Streptococcal bacteria most commonly cause an infection in the soft tissue around the tonsils (usually just on one side). The tissue is then invaded by anaerobes (bacteria that can live without oxygen), which enter through nearby glands. ASSESSMENT History Symptoms of peritonsillar abscess usually begin 3-5 days prior to evaluation.
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Fever Malaise Headache Neck pain Throat pain markedly more severe on the affected side and occasionally referred to the ipsilateral ear Dysphagia Change in voice Otalgia Odynophagia

Physical Physical findings of peritonsillar abscess include the following:

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Mild/moderate distress Fever Tachycardia Dehydration Drooling, salivation, trouble handling oral secretions Trismus resulting from pain from inflammation and spasm of masticator muscles Hot potato/muffled voice Rancid or fetor breath Cervical lymphadenitis in the anterior chain

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Asymmetric tonsillar hypertrophy Localized fluctuance Inferior and medial displacement of the tonsil Contralateral deviation of the uvula Erythema of the tonsil Exudates on the tonsil

Exams and Tests Peritonsillar abscess is usually diagnosed based on history and physical examination. A peritonsillar abscess is easy to diagnose when it is large enough to see. The doctor will look into your mouth using a light and, possibly, atongue depressor. Swelling and redness on one side of the throat near the tonsil suggests an abscess. The doctor may also gently push on the area with a gloved finger to see if there is pus from infection inside. Lab tests and x-rays are not used often. Sometimes an x-ray or an ultrasound will be performed, typically to make sure other upper airway illnesses are not present.

Management Appropriate Healthcare Children: Hospitalize for IV antibiotics Adults: Outpatient unless dehydrated or toxic Antibiotics for 10-14 days Base antibiotic choice on needle aspiration sample Parenteral a. Combination i. Penicillin G 10 MU IV every 6 hours and ii. Metronidazole 1.0 g load, and then 500 mg IV every 6 hours b. Cefoxitin 2 g IV q8h c. Clindamycin 900 mg IV every 8 hours d. Timentin e. Piperacillin f. Ampicillin with Sulbactam (Unasyn) 3 grams every 6 hours Oral agents . Clindamycin 500 mg PO bid a. Second and Third Generation Cephalosporins b. Augmentin 875 mg orally twice daily c. Combination . Penicillin VK 500 mg orally every 6 hours and i. Metronidazole 500 mg orally every 6 hours B. Experimental: Corticosteroids as adjunct to antibiotics Do not use routinely until larger studies are completed 1. 2. A. 1. 2.

Patients improved faster when adjunctive steroids were used . Protocol used Depo Medrol 2-3 mg/kg up to 250 mg IV for 1 dose Medical Management
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Patients with dehydration require intravenous fluid administration until the inflammation resolves and they are able to resume an adequate oral fluid intake. Antipyretics and analgesics are used to alleviate fever and discomfort. Oral and parenteral analgesics are an integral part of the management and allow the patient to resume oral intake. Often, the pain relief is so significant from I&D as to allow the patient to resume oral intake with nonnarcotic analgesics. Antibiotic therapy should begin after cultures are obtained from the abscess. The use of high-dose intravenous penicillin remains a good choice for the empiric treatment of PTA. Alternatively, due to the polymicrobial nature of cultured pus, agents that treat copathogens and resist beta-lactamases also have been recommended as a first choice. Cephalexin or other cephalosporins (with or without metronidazole) are likely the best initial option. Alternatives include (1) cefuroxime or cefpodoxime (with or without metronidazole), (2) clindamycin, (3) trovafloxacin, or (4) amoxicillin/clavulanate (if mononucleosis has been ruled out). The patient may be prescribed oral antibiotics once oral intake is tolerated; length of treatment should be 7-10 days. The use of steroids has been controversial. In a study by Ozbek, the addition of a single dose of intravenous dexamethasone to parenteral antibiotics has been found to significantly lessen the variables of hours hospitalized, throat pain, fever, and trismus compared with a group of patients who were only treated with parenteral antibiotics.5 In addition, the use of steroids in patients presenting with signs and symptoms of mononucleosis has not led to the formation of a peritonsillar abscess.

Surgical Management Needle aspiration

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Needle aspiration can be carried out in children as young as 7 years, especially if conscious sedation is used. Needle aspiration may be used both as a diagnostic and as a therapeutic modality because it allows the accurate localization of the abscess cavity. The fluid aspirated may be sent for culture and, in some cases, may not need to be followed by an I&D.

Incision and drainage

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Intraoral incision and drainage is performed by incising the mucosa overlying the abscess, usually located in the supratonsillar fold. Once the abscess is localized, blunt dissection is carried out to break loculations.

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The opening is left open to drain, and the patient is asked to gargle with a sodium chloride solution, allowing the accumulated material to exit the abscess cavity. A successful aspirate or drainage leads to immediate improvement of the patient's symptoms.

Other concerns
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In very young or uncooperative patients or when the abscess is located in an unusual location, the procedure is best performed under general anesthesia. Immediate tonsillectomy as part of the management of a PTA also has been a subject of controversy. Many studies have shown the safety of a tonsillectomy in the setting of an acute abscess. Others have shown that immediate or delayed tonsillectomy may not be necessary because of the high rate of success and low rates of recurrence and morbidity associated with intraoral drainage. In situations in which the abscess is located in an area difficult to access, a tonsillectomy may be the only way to drain the abscess.

Follow-up Most patients treated with antibiotics and adequate drainage of their abscess cavity recover within a few days. If patients continue to report recurring and/or chronic sore throats, a tonsillectomy may be indicated (Tonsillectomy 3-6 months after peritonsillar abscess).

Nursing Management Diagnosis:  Acute Pain  Risk for ineffective airway clearance  Deficient fluid volume

Planning and Implementation: y y y Teach that ice-cold fluids may be easier to swallow than hot or room-temperature beverages and may provide local analgesic effect. Advise to avoid citrus juices, hot or spicy and rough textured foods for 1 week. Teach pain management strategies such as applying ice collar as desired and gargling warm saline or mouthwash solution every 1 to 2 hours for the first 24-48 hours after aspiration of the abscess. Instruct to take medications as prescribed.