Peritonsillar Abscess 

Peritonsillar Abscess - this is a full patient education video about peritonsillar abscess.
Peritonsillar abscesses are pus collections next to the tonsils, they usually progress from tonsillitis to cellulitis and ultimately to abscess formation.
Weber glands are thought to also play a key role in the etiology of the infection. If these glands become inflamed, local cellulitis develops. As the infection progresses, inflammation worsens and results in tissue necrosis and pus formation.
Most infections occur during November to December and April to May, which coincide with the highest incidence rates of streptococcal pharyngitis and exudative tonsillitis.
Symptoms of peritonsillar abscess usually begin 3-5 days prior to evaluation they start with:
• 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 findings of peritonsillar abscess include the following:
• Mild/moderate distress
• Fever
• Tachycardia
• Dehydration
• Drooling, salivation, due to trouble handling oral secretions
• Trismus resulting from pain from inflammation and spasm of masticator muscles
• Hot potato/muffled voice
• Rancid breath
• Cervical lymphadenitis in the anterior chain
• Asymmetric tonsillar hypertrophy
• Localized fluctuance
• Inferior and medial displacement of the tonsil
• Contralateral deviation of the uvula
• Erythema and Exudates of the tonsil
Peritonsillar abscesses are usually polymicrobial. That means that it can be caused by multiple bacterias simultaneously.
No definitive studies are required to diagnose peritonsillar abscess. However we may consider basic laboratory tests (ie, CBC, electrolytes, C-reactive protein) if the patient has significant comorbidities.
Infectious mononucleosis can coexist in 2-6% of patients.
Culture of the fluid from needle aspiration may be performed to guide antibiotic selection or changes.
Care in the Emergency Department
Evaluation of peritonsillar abscesses begins with ABCs, paying close attention to the patient's airway. If the patient's airway is compromised, immediate endotracheal intubation is indicated. If this cannot be completed, a cricothyroidotomy or a tracheostomy may be required.
These patients often need IVFs since they have probably not kept up with drinking due to pain and water losses through salivation and drooling.
Antipyretics should be administered for elevated temperature; adequate analgesia should be provided for pain.
Acute surgical management should be carried out:
this involves needle aspiration or even surgical drainage.
Empiric antibiotics should be administered. Empiric therapy starts with Penicillin but if allergic Clindamicyn is the second best choice.
Steroids are often used as adjunctive treatment. patients treated with steroids have statistically significant reductions in pain and hospital stay.
Patients can be managed in an outpatient setting unless they show signs of toxicity, sepsis, airway compromise, inability to swallow, or other complications. These need to be managed in-hospital where ENT consultation is available.
Complications of peritonsillar abscess may include the following:
Necrotizing soft tissue infection of the neck and chest wall
Recurrence
Aspiration, which may lead to pneumonia or pneumonitis
Cervical abscess
Mediastinitis / Meningitis
Sepsis / Cerebral abscess
Jugular vein thrombosis
Carotid artery rupture/necrosis
Carotid artery injury (from I&D or needle aspiration)
the recurrence rate is 10%, regardless of whether a patient is treated with needle aspiration or incision and drainage.
Finally if you believe you have a peritonsillar abscess you should seek medical attention immediately. IF you were already dx with peritonsillar abscess but are feeling worse, have high fevers, are unable to swallow and hydrate yourself, then you must return to the ER as soon as possible.