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Peritonsillar Absess

Image: “A right sided peritonsilar abscess” by James Heilman,MD – Own work. License: CC BY-SA 3.0

Epidemiology of Peritonsillar Abscess

Peritonsillar abscess affects males and females equally. It commonly affects people between the ages of 20 and 40. The disease is less common in young individuals unless they are immunocompromised. Multiple failed attempts to treat tonsillitis with oral antibiotics and chronic tonsillitis may predispose the individual to develop a peritonsillar abscess.

Peritonsillar abscess patient data from a few countries like Denmark, Ireland, and the United States, noted the number of cases as 10 to 40 per 1 lac.

Causes of Peritonsillar Abscess

A peritonsillar abscess can be caused by both aerobic and anaerobic bacteria. Aerobic bacteria include staphylococcusstreptococcus, and hemophilus. Anaerobic bacteria include bacteroides, fusobacterium necrophorum, and peptostreptococcus prevotella species. A peritonsillar abscess usually arises as a complication of untreated or partially treated tonsillitis. The peritonsillar space has a large amount of loose connective tissue and therefore is more prone to the formation of an abscess and collection of pus.

Risk Factors of Peritonsillar Abscess

The following are the risk factors for the development of a peritonsillar abscess:

  • Dental infections
  • Gingivitis
  • Infectious mononucleosis
  • Smoking
  • Chronic lymphocytic leukemia

Pathophysiology of Peritonsillar Abscess

A specialized portion of the intrapharyngeal aponeurosis covers the medial side of the tonsils and provides a space for the passage of blood vessels. It also covers the capsule of the tonsil, so the space between the tonsil and the capsule is a potential space for the formation of an abscess.

The peritonsillar space is continuous with several other deeper spaces in the neck, such as the parapharyngeal and retropharyngeal spaces. The infection can spread into these spaces as well.

There are numerous small salivary glands in the soft palate and superior to the tonsil, known as weber glands, and they are thought to play an important role in the etiology of infection. If these glands become inflamed, then cellulitis develops, which progresses to inflammation and ultimately leads to necrosis and pus formation.

Signs and Symptoms of Peritonsillar Abscess

  • Peritonsillar abscess

    Image: “Peritonsillar abscess on the person’s right.” by James Heilman, MD – Own work. License: CC BY-SA 4.0

    Severely sore throat on the affected side

  • Odynophagia (pain during swallowing)
  • Fever
  • Malaise
  • Headache
  • Hot potato voice (distortion of vowels)
  • Referred ear pain
  • Tender swollen jugulodiagastric lymph nodes
  • Foul breath
  • Uvula may be displaced to the unaffected side
  • Erythema and exudates on tonsils
  • Drooling of saliva
  • Trismus
  • Dehydration
  • Lymph glands of the neck may be enlarged
  • In severe infections, the throat may be blocked, which can cause difficulty breathing.

Diagnosis of Peritonsillar Abscess

There is no definitive diagnosis of peritonsillar abscess. Diagnosis is usually based on the presentation of the patient and presenting signs and symptoms.

Basic studies, such as a complete blood count and C-reactive protein, can be done. A Monospot test can be done if infectious mononucleosis is being suspected. Needle aspiration of the fluid can be done to find out the exact organism. Blood cultures can also be done according to the severity of the case.

A lateral neck radiograph can be done to rule out any other cause. Intraoral ultrasonography is also sometimes helpful for reaching a diagnosis. A CT scan of the head and neck can also be considered in cases where the patient is an uncooperative child or cannot open the mouth.

Management and Treatment of Peritonsillar Abscess

If a patient with peritonsillar abscess arrives presents to the emergency department, the first steps are maintaining the airway and providing adequate fluid resuscitation. Antipyretics should be administered in the case of fever; patients with severe pain may be given analgesics.

Definitive treatment includes incision and drainage of the pus, needle aspiration, and tonsillectomy if the patient presents with recurrent abscess formations. Most ENT surgeons prefer to wait and watch before doing a tonsillectomy if the patient presents with an abscess for the first time.

Antibiotics are also given to treat cases of acute infection. The infection is considered penicillin-resistant, so treatment includes clindamycin or metronidazole combined with penicillin or amoxicillin/clavulanate.

Overview of Management of Peritonsillar Abscess

If deeper infection suspected If not yet drainable If drainable
Study of choice
  • Ampicillin/sulbactam is the first line (transition to amoxicillin/clavulanate)
  • Second-line clindamycin
  • Steroids indicated only if acute airway obstruction
ENT consult for I and D is indicated

Complications of Peritonsillar Abscess

  • Sepsis
  • Shock
  • Decreased oral intake
  • Dehydration
  • Extension of the abscess into other deep spaces of the neck
  • Glomerulonephritis and rheumatic fever
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