Transcript Presentation and Discussion of a Patient with “Pharyngitis”

Peritonsillar Abscess
Celina Martinez, MSIII
April 25, 2006
Clinical Presentation of A.E.
• 47 y.o. AAF c/o “sore throat” and difficulty
swallowing for 4 days
• PMH
– None
• Meds
– None
• SH
– Current cigarette use with 20 pack-year history
– Moderate EtOH use, current heroin use
• ROS
– + fever, throat pain, cough, wheezing, dysphagia
– Throat pain is 7/10
Physical Exam
VS: 137/86
HR 103
T 100.8
98-100% RA
HEENT:
– + lymphadenopathy bilaterally
– Unable to visualize oropharynx, patient cannot fully
open mouth
Repeat exam of oropharynx
– L tonsil swollen, with exudate
– Uvula midline
Labs
11.8
13,460
264
35.2
P = 82%
L = 14%
M = 4%
9.0 6.9 0.6 17
3.8
11
Alk Phos – 69
144 105 11
3.1 29 0.6
Glucose – 98
Differential Diagnosis
• Viral
– Rhinovirus, coronavirus,
adenovirus
– Influenza
– Parainfluenza
– Coxsackie virus
– HSV
– CMV
– HIV
• Bacterial
–
–
–
–
–
–
GAβS
Gonococci
Chlamydia
Diphtheria
Legionella
Mycoplasma
• Anatomically related
conditions
–
–
–
–
–
–
–
Epiglottitis
Peritonsillar abscess
Retropharyngeal abscess
Candidal pharyngitis
Apthous stomatitis
Thyroiditis
Bullous erythema
multiforme
Imaging
• Neck CT with Contrast
– L tonsillar enlargement with 2 rim-enhancing
peritonsillar hypodensities
– Oropharyngeal narrowing at level of tonsillar
enlargement
– Swelling of adjacent soft palate with hypodensity
compatible with fluid that crosses the midline
• Impression
– Enlargement of the left palatine tonsil with
cystic/necrotic change and marked swelling of
adjacent structures
Peritonsillar Abscess
Background
– 30 cases per 100,000 people per year
• 45,000 US cases annually
– Highest incidence in 3rd and 4th decades of life
Differential Diagnosis
•Peritonsillar cellulitis
•Tonsillar abscess
•Mononucleosis
•FB aspiration
•Cervical adenitis
•Neoplasm
•Dental infection
•Salivary gland tumor
•Aneurysm of internal
carotid artery
Peritonsillar Abscess
Pathophysiology - Progression of tonsillitis
Tonsillitis  Peritonsilar Inflammation  Abscess
• Inflammation of supratonsillar soft palate and
surrounding muscle
• Pus collects between fibrous capsule and superior
constrictor muscle of the pharynx
– Common infectious agents
• Common aerobes
– Streptococcus pyogenes in 30%
– H. influenzae, S. aureus, neisseria species
• Common anaerobes
– Fusobacterium, peptostreptococcus, prevotella,
bacteroides
Peritonsillar Abscess
Symptoms
– Sore throat
– Dysphagia
– Difficulty opening
mouth
– “Hot potato voice”
– Headache
– Neck pain
– Referred ear pain
– General malaise
Signs
–
–
–
–
–
–
Fever
Trismus
Drooling, salivation
Lymphadenopathy
Dehydration
Signs of airway
compromise (rare)
– Oropharyngeal exam
Oropharyngeal Exam
– Edema of tissues lateral and superior to the involved
tonsil
– Medial and/or anterior displacement of the involved
tonsil
– Displacement of the uvula to the contralateral side of
the pharynx
– Possibly erythematous, enlarged, or exudate-covered
tonsil
Peritonsillar Abscess
Diagnosis is usually clinical!
Other Tests
– Intraoral ultrasound
• Rule out retropharyngeal abscess and peritonsillar
cellulitis
– CT scan
• Trismus, suspicion of invasion into deep neck
tissue
Peritonsillar Abscess
Treatment
– IV hydration
– IV steroids
– IV pain control
– Antibiotics
• Penicillin V 500 mg TID for 10-14 days
• Metronidazole 500 mg BID for 10-14 days
OR
• Clindamycin 300 mg QID for 10 days
Peritonsillar Abscess
Treatment
– Needle aspiration
• Anesthetic spray, 2-4 cc of lidocaine w/epi
• 19-gauge needle; keep proximal half covered
w/cap
• Point needle medially, keep medial to molars to
avoid vessels!
• Needle can be inserted 1-2 cm safely
• Culture aspirate and gram stain aspirate
Peritonsillar Abscess
• When to defer to otolaryngology
– Marked trismus
– Unsuccessful aspiration
– Deep neck invasion
Current Literature
• 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.
– NSTI from peritonsillar abscess is rapidly spreading
and life threatening.
– High index of suspicion, early diagnosis, broadspectrum antibiotics and aggressive surgical
management are essential.
• Fasano CJ, Chudnofsky C, Vanderbeek P. Bilateral
peritonsillar abscesses: not your usual sore throat.
Emerg Med. 2005 Jul;29(1):45-7.
– Bilateral tonsil swelling, midline uvula
References
•
•
•
•
Johnson RF, Stewart MG. The contemporary approach to diagnosis and
management of peritonsillar abscess. Curr Opin Otolaryngol Head Neck
Surg. 2005 Jun;13(3):157-60.
Thomas GR, et al. Managing Common Otolaryngologic Emergencies.
Emerg Med 37(5):18-47, 2005.
Bisno AL. Acute Pharyngitis. N Engl J Med. 2001 Jan 18;344(3):205-11
Steyer TE. Peritonsillar Abscess: Diagnosis and Treatment. Am Fam
Physician. 2002 Jan 1;65(1):93-6.