Peritonsillar Abscess in Emergency Medicine
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Peritonsillar abscesses (PTAs) are common infections of the head and neck region, accounting for approximately 30% of soft tissue head and neck abscesses. With an incidence of about 1 in 10,000, PTA (see the image below) is the most common deep space infection of the head and neck that presents to the emergency department.
A study by Johnson using the 2012 Nationwide Emergency Department Sample, the 2012 National (Nationwide) Inpatient Sample, and the 2013 Nationwide Readmissions Database estimated the number of emergency department visits in the United States for peritonsillar abscess to be 62,787, with the estimated number of inpatient admissions and readmissions for the condition being 15,095 and 267, respectively. Eighty percent of the emergency department patients were discharged home after receiving nonoperative therapy, while 50% of the patients admitted to the hospital were treated surgically. [1]
Symptoms of PTA usually begin 3-5 days before evaluation and may include the following:
Fever
Malaise
Headache
Neck pain
Throat pain (more severe on the affected side; occasionally referred to the ipsilateral ear)
Dysphagia
Change in voice
Otalgia
Odynophagia
Physical findings may include the following:
Mild-to-moderate distress
Fever
Tachycardia
Dehydration
Drooling, salivation, or trouble handling oral secretions
Trismus
“Hot potato” or muffled voice
Rancid or fetid 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 of the tonsil
Exudates on the tonsil
See Presentation for more detail.
No definitive studies are required to diagnose PTA. The following laboratory tests may be considered:
Basic studies, such as complete blood count, electrolytes, and C-reactive protein (if the patient has significant comorbidities)
Monospot test/heterophile antibody test (to rule out infectious mononucleosis if the etiology is unclear)
Culture of fluid from needle aspiration (to guide antibiotic selection or changes)
Blood cultures (if the clinical presentation is severe)
The following imaging studies may be considered:
Lateral soft tissue neck radiography (to help rule out other causes)
Intraoral ultrasonography
Computed tomography (CT) of the head and neck with intravenous (IV) contrast (if incision and drainage fails, if the patient cannot open his or her mouth, or if the patient is young and uncooperative)
See Workup for more detail.
Initial management of PTA may include the following:
Transport with supplemental oxygen.
Attention to the ABCs (airway, breathing, and circulation)
If the patient’s airway is compromised, immediate endotracheal intubation or, if this cannot be accomplished, cricothyroidotomy or tracheostomy; alternatively, awake fiberoptic bronchoscopy
Fluid resuscitation as necessary
Antipyretics for elevated temperature
Adequate analgesia for pain
If acute surgical management of PTA is indicated, the following 3 options are available:
Needle aspiration
Incision and drainage
Quinsy tonsillectomy (eg, simultaneous tonsillectomy with open abscess drainage)
Additional pharmacologic therapy may include the following:
Empiric antibiotics
Adjunctive steroids
See Treatment and Medication for more detail.
Peritonsillar abscesses (PTAs) are common infections of the head and neck region; they comprise approximately 30% of soft tissue head and neck abscesses. [2] With an incidence of about 1 in 10,000, it is the most common deep space infection of the head and neck that presents to the emergency department. [3]
A study by Johnson using the 2012 Nationwide Emergency Department Sample, the 2012 National (Nationwide) Inpatient Sample, and the 2013 Nationwide Readmissions Database estimated the number of emergency department visits in the United States for peritonsillar abscess to be 62,787, with the estimated number of inpatient admissions and readmissions for the condition being 15,095 and 267, respectively. Eighty percent of the emergency department patients were discharged home after receiving nonoperative therapy, while 50% of the patients admitted to the hospital were treated surgically. [1]
Physicians must be aware of the typical clinical presentation of and diagnostic strategies for peritonsillar abscess, in order to quickly diagnose and appropriately treat patients with the condition. In this way, complications and further propagation of the infectious process can be prevented.
A peritonsillar abscess is shown in the image below.
The two palatine tonsils are on the lateral walls of the oropharynx, within the depression between the anterior and posterior tonsillar pillars. Each pillar is composed primarily of the glossopalatine and the pharyngopalatine muscles.
During embryonic development, the tonsils arise from the second pharyngeal pouch as buds of endodermal cells. [4] The tonsils then grow irregularly and reach their ultimate size and shape at approximately age 6-7 years.
Each tonsil is surrounded by a capsule, a specialized portion of the intrapharyngeal aponeurosis that covers the medial portion of the tonsils and provides a path for blood vessels and nerves. [4] It is within this potential space, between the tonsil and capsule, that peritonsillar abscesses form. [5] Note that the peritonsillar space is anatomically contiguous with several deeper spaces, and infections can potentially involve the parapharyngeal and retropharyngeal spaces. [6]
Peritonsillar abscesses 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. These mucous salivary glands are located superior to the tonsil in the soft palate and clear the tonsillar area of debris. If these glands become inflamed, local cellulitis develops. As the infection progresses, inflammation worsens and results in tissue necrosis and pus formation, most commonly just above the superior pole of the tonsil where the glands are located. [5]
Klug et al, citing evidence for peritonsillar abscess as a complication of acute tonsillitis and as a consequence of Weber gland infection, hypothesized that peritonsillar abscesses develop when bacteria infect the tonsillar mucosa and then, using the salivary duct system, spread to the peritonsillar space. [7]
A multi-center, prospective, observational case-control study by Lepelletier et al suggested that self-medication with systemic anti-inflammatory drugs may increase the risk of peritonsillar abscess. Male gender and smoking were also linked to the condition. The study compared 120 cases of peritonsillar abscess with 143 cases of sore throat without peritonsillar abscess. [8]
In the United States, the incidence of peritonsillar abscess has been estimated at 30 cases per 100,000 persons per year, accounting for approximately 45,000 cases annually.It has also been estimated to result in at least $150 million a year in health care expenditures. [9] Most infections occur during November to December and April to May, which coincide with the highest incidence rates of streptococcal pharyngitis and exudative tonsillitis. [5]
A higher rate is reported internationally due to recurrence and antibiotic resistance.
Mortality of peritonsillar abscess is unknown. Morbidity of peritonsillar abscess is due mostly to pain, cost of treatment, lost time from work and school, and complications.
Using data from the National (Nationwide) Inpatient Sample, a study by Qureshi et al found evidence that retropharyngeal abscess is occurring at an increasing rate among adult inpatients with peritonsillar abscess. According to the investigators, between 2003 and 2010 the annual rate at which retropharyngeal abscess occurred concurrently with peritonsillar abscess rose from 0.5% to 1.4% among inpatients aged 18 years or older. The study also indicated that patient age affects concurrence of the two conditions, with the likelihood that retropharyngeal abscess will complicate peritonsillar abscess increasing in patients aged 40 years or older. [10]
No racial predilection of peritonsillar abscess is noted.
The male-to-female ratio for peritonsillar abscess is considered to be equal, although the previously mentioned study by Lepelletier did suggest that male gender is a risk factor. [8]
Peritonsillar abscess can occur in anyone aged 10-60 years according to one source, although peritonsillar abscess is most commonly seen in those aged 20-40 years. [11] The younger children who get peritonsillar abscess are often immunocompromised.
Johnson RF. Emergency department visits, hospitalizations, and readmissions of patients with a peritonsillar abscess. Laryngoscope. 2017 Oct. 127 Suppl 5:S1-S9. [Medline].
Johnson RF, Stewart MG, Wright CC. An evidence-based review of the treatment of peritonsillar abscess. Otolaryngol Head Neck Surg. 2003 Mar. 128(3):332-43. [Medline].
Herzon FS, Martin AD. Medical and surgical treatment of peritonsillar, retropharyngeal, and parapharyngeal abscesses. Curr Infect Dis Rep. 2006 May. 8(3):196-202. [Medline].
Steyer TE. Peritonsillar abscess: diagnosis and treatment. Am Fam Physician. 2002 Jan 1. 65(1):93-6. [Medline].
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Lepelletier D, Pinaud V, Le Conte P, et al. Is there an association between prior anti-inflammatory drug exposure and occurrence of peritonsillar abscess (PTA)? A national multicenter prospective observational case-control study. Eur J Clin Microbiol Infect Dis. 2017 Jan. 36 (1):57-63. [Medline].
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Qureshi HA, Ference EH, Tan BK, et al. National Trends in Retropharyngeal Abscess among Adult Inpatients with Peritonsillar Abscess. Otolaryngol Head Neck Surg. 2015 Jan 20. [Medline].
Herzon FS. Harris P. Mosher Award thesis. Peritonsillar abscess: incidence, current management practices, and a proposal for treatment guidelines. Laryngoscope. 1995 Aug. 105(8 Pt 3 Suppl 74):1-17. [Medline].
Sakae FA, Imamura R, Sennes LU, Araujo Filho BC, Tsuji DH. [Microbiology of peritonsillar abscesses]. Rev Bras Otorrinolaringol (Engl Ed). 2006 Mar-Apr. 72(2):247-51. [Medline].
Klug TE, Henriksen JJ, Fuursted K, Ovesen T. Significant pathogens in peritonsillar abscesses. Eur J Clin Microbiol Infect Dis. 2011 May. 30(5):619-27. [Medline].
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Huang Z, Vintzileos W, Gordish-Dressman H, Bandarkar A, Reilly BK. Pediatric peritonsillar abscess: Outcomes and cost savings from using transcervical ultrasound. Laryngoscope. 2017 Jan 16. [Medline].
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Rahn R, Hutten-Czapski P. Quinsy (peritonsillar abscess). Can J Rural Med. 2009 Winter. 14(1):25-6. [Medline].
Bovo R, Barillari MR, Martini A. Hospital discharge survey on 4,199 peritonsillar abscesses in the Veneto region: what is the risk of recurrence and complications without tonsillectomy?. Eur Arch Otorhinolaryngol. 2015 Jan 11. [Medline].
Chau JK, Seikaly HR, Harris JR, Villa-Roel C, Brick C, Rowe BH. Corticosteroids in peritonsillar abscess treatment: a blinded placebo-controlled clinical trial. Laryngoscope. 2014 Jan. 124 (1):97-103. [Medline].
Lee YJ, Jeong YM, Lee HS, Hwang SH. The Efficacy of Corticosteroids in the Treatment of Peritonsillar Abscess: A Meta-Analysis. Clin Exp Otorhinolaryngol. 2016 Jun. 9 (2):89-97. [Medline]. [Full Text].
Losanoff JE, Missavage AE. Neglected peritonsillar abscess resulting in necrotizing soft tissue infection of the neck and chest wall. Int J Clin Pract. 2005 Dec. 59(12):1476-8. [Medline].
Chen MM, Roman SA, Sosa JA, Judson BL. Safety of Adult Tonsillectomy: A Population-Level Analysis of 5968 Patients. JAMA Otolaryngol Head Neck Surg. 2014 Jan 30. [Medline].
Melville NA. Adult tonsillectomy shown to be safe, with few complications. Medscape Medical News. 2014 Feb 4. [Full Text].
Jorge Flores, MD Resident Physician, Department of Emergency Medicine, Kings County Hospital Center, SUNY Downstate Medical Center
Jorge Flores, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, Emergency Medicine Residents’ Association
Disclosure: Nothing to disclose.
Audrey J Tan, DO Staff Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center, Kings County Hospital Center
Audrey J Tan, DO is a member of the following medical societies: American College of Emergency Physicians, American Medical Association
Disclosure: Nothing to disclose.
Ninfa Mehta, MD, MPH Clinical Assistant Professor, Ultrasound Fellowship Director, Department of Emergency Medicine, Kings County Hospital, State University of New York Downstate Medical Center
Ninfa Mehta, MD, MPH is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, American Medical Student Association/Foundation, Society for Academic Emergency Medicine, American Association of Physicians of Indian Origin
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician, Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Palmetto Richland Hospital
Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Columbia Medical Society, Society for Academic Emergency Medicine, South Carolina College of Emergency Physicians, South Carolina Medical Association
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Employed contractor – Chief Editor for Medscape.
Michael Glick, DMD Dean, University of Buffalo School of Dental Medicine
Michael Glick, DMD is a member of the following medical societies: American Academy of Oral Medicine, American Dental Association
Disclosure: Nothing to disclose.
Mazen J El-Sayed, MD Resident Physician, Department of Emergency Medicine, University of Maryland Medical Center
Disclosure: Nothing to disclose.
Mark W Fourre, MD Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine; Program Director, Department of Emergency Medicine, Maine Medical Center
Disclosure: Nothing to disclose.
A Antoine Kazzi, MD Deputy Chief of Staff, American University of Beirut Medical Center; Associate Professor, Department of Emergency Medicine, American University of Beirut, Lebanon
A Antoine Kazzi, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.
Peritonsillar Abscess in Emergency Medicine
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