Pediatric Peritonsillar Abscess

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Pediatric Peritonsillar Abscess

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Peritonsillar abscess (PTA) is a suppurative infection of the tissues between the capsule of the palatine tonsil and pharyngeal muscles and is the most common abscess of the head and neck region. It is usually unilateral but can be bilateral in about 6% of instances. [1] Peritonsillar abscess (also known as quinsy) is the commonest of all deep neck infections. [2] Other deep neck infections include retropharyngeal abscess and parapharyngeal (lateral pharyngeal) space abscess. [3]

Peritonsillar abscess generally occurs in the superior pole of the tonsil. It can also be present at the midpoint or inferior pole of the tonsil or have multiple loculations within the peritonsillar space. The development of the abscess is often gradual, with an early stage of peritonsillar cellulitis. If not properly treated, an abscess emerges.

Two mechanisms have been proposed to explain the development of a collection of pus in the loose connective tissue of the supratonsillar fossa. The more common explanation is that a peritonsillar abscess develops from an inadequately treated bacterial tonsillitis. An alternative explanation is that a peritonsillar abscess is an abscess formed in a group of salivary glands in the supratonsillar fossa, known as Weber glands.

Lymphatic drainage from an infected peritonsillar abscess is to the ipsilateral jugulodigastric nodes. Bacterial cultures that are also adequate for the recovery of anaerobic bacteria usually yield polymicrobial aerobic and anaerobic bacteria. Group A beta-hemolytic streptococci is recovered in 25-40% of the abscesses. Anaerobic bacteria is isolated in over 90% of aspirated pus, [4] and elevated antibody levels to these organisms is detected in most patients with peritonsillar abscess. [5] Methicillin-resistant Staphylococcus aureus (MRSA) has been isolated with greater frequency in peritonsillar abscesses in recent years. [6]

United States

The estimated incidence in the United States is 30 cases per 100,000 person-years in patients aged 5-59 years. [7] The incidence in children younger than 18 years is 14 cases per 100,000 population. Approximately 25-30% of patients with peritonsillar abscess are in the pediatric age group. [8]

A study by Qureshi et al analyzed temporal trends in the incidence and surgical management of children with peritonsillar abscesses. The study found that there was no change in the incidence from 2000 to 2009 but there was a change in surgical management, with a significant decrease in the rate of tonsillectomy and significant increase in the rate of incision and drainage procedures. [9]

International

The incidence of peritonsillar abscess in Ontario, Canada was 12 cases in 100,000 population. [10]

The mean annual incidence of peritonsillar abscess in Europe was 41 cases in 100,000 population. [11]

The mortality rate is unknown. Mortality is often due to aspiration of a ruptured abscess or sequelae of sepsis. Morbidity stems principally from pain and dehydration. See Complications in the Follow-up section.

No race predilection is known.

No sex predilection is reported.

Peritonsillar abscess most commonly occurs in the third and fourth decades of life. Pediatric cases are more common in children older than 10 years, although cases have been described in children younger than 1 year.

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Brodsky L, Sobie SR, Korwin D, Stanievich JF. A clinical prospective study of peritonsillar abscess in children. Laryngoscope. 1988 Jul. 98(7):780-3. [Medline].

Maroldi R, Farina D, Ravanelli M, Lombardi D, Nicolai P. Emergency imaging assessment of deep neck space infections. Semin Ultrasound CT MR. 2012 Oct. 33(5):432-42. [Medline].

Brook I. Non-odontogenic abscesses in the head and neck region. Periodontol 2000. 2009 Feb. 49:106-25. [Medline].

Baker KA, Stuart J, Sykes KJ, Sinclair KA, Wei JL. Use of computed tomography in the emergency department for the diagnosis of pediatric peritonsillar abscess. Pediatr Emerg Care. 2012 Oct. 28(10):962-5. [Medline].

Scott PM, Loftus WK, Kew J, Ahuja A, Yue V, van Hasselt CA. Diagnosis of peritonsillar infections: a prospective study of ultrasound, computerized tomography and clinical diagnosis. J Laryngol Otol. 1999 Mar. 113(3):229-32. [Medline].

Fordham MT, Rock AN, Bandarkar A, Preciado D, Levy M, Cohen J, et al. Transcervical ultrasonography in the diagnosis of pediatric peritonsillar abscess. Laryngoscope. 2015 Dec. 125 (12):2799-804. [Medline].

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Kew J, Ahuja A, Loftus WK, Scott PM, Metreweli C. Peritonsillar abscess appearance on intra-oral ultrasonography. Clin Radiol. 1998 Feb. 53(2):143-6. [Medline].

Kieff DA, Bhattacharyya N, Siegel NS, Salman SD. Selection of antibiotics after incision and drainage of peritonsillar abscesses. Otolaryngol Head Neck Surg. 1999 Jan. 120(1):57-61. [Medline].

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Scott PM, Loftus WK, Kew J, Ahuja A, Yue V, van Hasselt CA. Diagnosis of peritonsillar infections: a prospective study of ultrasound, computerized tomography and clinical diagnosis. J Laryngol Otol. 1999 Mar. 113(3):229-32. [Medline].

Spires JR, Owens JJ, Woodson GE, Miller RH. Treatment of peritonsillar abscess. A prospective study of aspiration vs incision and drainage. Arch Otolaryngol Head Neck Surg. 1987 Sep. 113(9):984-6. [Medline].

Stringer SP, Schaefer SD, Close LG. A randomized trial for outpatient management of peritonsillar abscess. Arch Otolaryngol Head Neck Surg. 1988 Mar. 114(3):296-8. [Medline].

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Itzhak Brook, MD, MSc Professor, Department of Pediatrics, Georgetown University School of Medicine

Itzhak Brook, MD, MSc is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society for Microbiology, Association of Military Surgeons of the US, Infectious Diseases Society of America, International Immunocompromised Host Society, International Society for Infectious Diseases, Medical Society of the District of Columbia, New York Academy of Sciences, Pediatric Infectious Diseases Society, Society for Experimental Biology and Medicine, Society for Pediatric Research, Southern Medical Association, Society for Ear, Nose and Throat Advances in Children, American Federation for Clinical Research, Surgical Infection Society, Armed Forces Infectious Diseases Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Joseph Domachowske, MD Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York Upstate Medical University

Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa

Disclosure: Received research grant from: Pfizer;GlaxoSmithKline;AstraZeneca;Merck;American Academy of Pediatrics, Novavax, Regeneron, Diassess, Actelion<br/>Received income in an amount equal to or greater than $250 from: Sanofi Pasteur.

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, Southern Medical Association

Disclosure: Nothing to disclose.

Ashir Kumar, MD, MBBS FAAP, Professor Emeritus, Department of Pediatrics and Human Development, Michigan State University College of Human Medicine

Ashir Kumar, MD, MBBS is a member of the following medical societies: Infectious Diseases Society of America, American Association of Physicians of Indian Origin

Disclosure: Nothing to disclose.

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Gershon Segal, MD, to the development and writing of this article.

Pediatric Peritonsillar Abscess

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Pediatric Peritonsillar Abscess
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