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| {{Infobox_Disease | | __NOTOC__ |
| | Name = Peritonsillar abscess
| | {{Peritonsillar abscess}} |
| | Image =
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| | Caption =
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| | DiseasesDB = 11141
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| | ICD10 = {{ICD10|J|36||j|30}}
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| | ICD9 = {{ICD9|475}}
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| | ICDO =
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| | OMIM =
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| | MedlinePlus =
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| | eMedicineSubj = emerg
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| | eMedicineTopic = 417
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| | MeshID =
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| }}
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| __Notoc__
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| {{SI}}
| | {{CMG}}; {{AE}} {{PTD}} |
| {{CMG}}; {{KS}} {{PTD}} | |
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| {{SK}} PTA, tonsillar abscess, intratonsillar abscess | | {{SK}} PTA, Tonsillar abscess, Intratonsillar abscess, Quinsy |
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| ==Overview==
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| Peritonsillar abscess (PTA), also commonly referred to as [[quinsy]], is defined as a collection of [[pus]] located between the tonsillar [[capsule]] and the [[pharyngeal]] [[Constrictor pharyngis medius|constrictor]] muscles.
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| It is the most common deep tissue infection of the neck.<ref name="pmid18246890">{{cite journal| author=Galioto NJ| title=Peritonsillar abscess. | journal=Am Fam Physician | year= 2008 | volume= 77 | issue= 2 | pages= 199-202 | pmid=18246890 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18246890 }} </ref>
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| Historically, it has been thought of as a complication of [[acute]] [[tonsillitis]]. However, recent studies have proposed additional [[hypothesis]] surrounding its [[pathogenesis]] making the understanding of the disease a medical dilemma.<ref name="pmid23612569">{{cite journal| author=Powell EL, Powell J, Samuel JR, Wilson JA| title=A review of the pathogenesis of adult peritonsillar abscess: time for a re-evaluation. | journal=J Antimicrob Chemother | year= 2013 | volume= 68 | issue= 9 | pages= 1941-50 | pmid=23612569 | doi=10.1093/jac/dkt128 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23612569 }} </ref>
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| ==Historical perspective== | | ==[[Peritonsillar abscess overview|Overview]]== |
| The outline below shows the historical perspective of peritonsillar abscess.<ref name="pmid8302122">{{cite journal| author=Passy V| title=Pathogenesis of peritonsillar abscess. | journal=Laryngoscope | year= 1994 | volume= 104 | issue= 2 | pages= 185-90 | pmid=8302122 | doi=10.1288/00005537-199402000-00011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8302122 }} </ref>
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| *In second and third century BC, Celcius was the first to document in literature the treatment and [[pathogenesis]] of tonsillar [[pathology]].
| | ==[[Peritonsillar abscess historical perspective|Historical Perspective]]== |
| *In 1700s peritonsillar abscess was first described.
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| *In the 1930s and 1940s prior to the advent of antibiotics, surgical management was the most common treatment option for peritonsillar abscess. Interval [[tonsillectomy]] was mostly done after symptom resolution.
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| *By 1947, Chaud [[tonsillectomy]] or immediate surgical [[tonsillectomy]] became the treatment option.
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| ==Classification== | | ==[[Peritonsillar abscess classification]]== |
| On the basis of computed tomographical findings, peritonsillar abscess may be classified into 3 broad categories based on the following:
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| 1. '''Shape of the abscess'''
| | ==[[Peritonsillar abscess pathophysiology|Pathophysiology]]== |
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| On the basis of shape it may be classified as:<ref name="pmid26527518">{{cite journal| author=Kawabata M, Umakoshi M, Makise T, Miyashita K, Harada M, Nagano H et al.| title=Clinical classification of peritonsillar abscess based on CT and indications for immediate abscess tonsillectomy. | journal=Auris Nasus Larynx | year= 2016 | volume= 43 | issue= 2 | pages= 182-6 | pmid=26527518 | doi=10.1016/j.anl.2015.09.014 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26527518 }} </ref>
| | ==[[Peritonsillar abscess causes|Causes]]== |
| *[[Oval]] type or
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| *Cap type
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| 2. '''Location of the abscess'''
| | ==[[Peritonsillar abscess differential diagnosis|Differentiating Peritonsillar abscess from other Diseases]]== |
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| On the basis of abscess location it may be differentiated into the following:<ref name="pmid26527518">{{cite journal| author=Kawabata M, Umakoshi M, Makise T, Miyashita K, Harada M, Nagano H et al.| title=Clinical classification of peritonsillar abscess based on CT and indications for immediate abscess tonsillectomy. | journal=Auris Nasus Larynx | year= 2016 | volume= 43 | issue= 2 | pages= 182-6 | pmid=26527518 | doi=10.1016/j.anl.2015.09.014 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26527518 }} </ref>
| | ==[[Peritonsillar abscess epidemiology and demographics|Epidemiology and Demographics]]== |
| *[[Superior]] or
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| *Inferior
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| 3. '''Shape and location'''
| | ==[[Peritonsillar abscess screening|Screening]]== |
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| On the basis of shaped and location it may be classified as:<ref name="pmid26527518">{{cite journal| author=Kawabata M, Umakoshi M, Makise T, Miyashita K, Harada M, Nagano H et al.| title=Clinical classification of peritonsillar abscess based on CT and indications for immediate abscess tonsillectomy. | journal=Auris Nasus Larynx | year= 2016 | volume= 43 | issue= 2 | pages= 182-6 | pmid=26527518 | doi=10.1016/j.anl.2015.09.014 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26527518 }} </ref>
| | ==[[Peritonsillar abscess risk factors|Risk Factors]]== |
| *[[Superior]] [[Oval]] type
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| *[[Superior]] Cap type
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| *Inferior [[Oval]] type and
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| *Inferior Cap type
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| ==Pathophysiology== | | ==[[Peritonsillar abscess natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| ===Anatomy===
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| A good understanding of the [[tonsil]] and its surrounding space is important in the [[pathogenesis]] of peritonsillar abscess.
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| The [[palatine tonsils]] are found in an anatomical structure called [[tonsillar fossa]]. This [[fossa]] is bounded anteriorly by palatoglossal muscle, posteriorly by palatopharyngeal muscle, laterally by a [[fibrous]] [[capsule]] and tonsillar crypts [[medially]]. Contents of the tonsillar crypts are expelled by [[contraction]] of the tonsillopharyngeus muscle.<ref name=abd>L. Michaels, H.B. Hellquist Ear, nose and throat histopathology (2nd ed.)Springer-Verlag, London (2001), pp. 281–286</ref> The [[tonsils]] form during the last months of [[pregnancy]] and becomes fully formed by 6 to 7 years of age. It then undergoes involution until small size remains in older population.
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| Located within the soft palate is the supratonsillar space occupied by series of 20 to 25 [[salivary glands]] described as Weber's glands. The [[ducts]] of these [[glands]] form a common [[duct]] which opens onto the [[posterior]] surface of the [[tonsil]] after passing through the tonsillar [[capsule]]. It is proposed that the secretions from these [[glands]] play a rule in food [[digestion]].
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| Peritonsillar abscesses form in the area between the [[Palatine tonsils|palatine tonsil]] and its [[capsule]].
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| ===Pathogenesis===
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| The [[pathogenesis]] of peritonsillar abscess is still not well-understood.<ref name="pmid23612569">{{cite journal| author=Powell EL, Powell J, Samuel JR, Wilson JA| title=A review of the pathogenesis of adult peritonsillar abscess: time for a re-evaluation. | journal=J Antimicrob Chemother | year= 2013 | volume= 68 | issue= 9 | pages= 1941-50 | pmid=23612569 | doi=10.1093/jac/dkt128 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23612569 }} </ref> There are two proposed theories believed to be involved in the pathogensis of peritonsillar abscess formation.<ref name=abd>L. Michaels, H.B. Hellquist Ear, nose and throat histopathology (2nd ed.)Springer-Verlag, London (2001), pp. 281–286</ref><ref name="pmid8302122">{{cite journal| author=Passy V| title=Pathogenesis of peritonsillar abscess. | journal=Laryngoscope | year= 1994 | volume= 104 | issue= 2 | pages= 185-90 | pmid=8302122 | doi=10.1288/00005537-199402000-00011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8302122 }} </ref><ref name="pmid25865201">{{cite journal| author=Blair AB, Booth R, Baugh R| title=A unifying theory of tonsillitis, intratonsillar abscess and peritonsillar abscess. | journal=Am J Otolaryngol | year= 2015 | volume= 36 | issue= 4 | pages= 517-20 | pmid=25865201 | doi=10.1016/j.amjoto.2015.03.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25865201 }} </ref><ref name="pmid16643771">{{cite journal| author=Herzon FS, Martin AD| title=Medical and surgical treatment of peritonsillar, retropharyngeal, and parapharyngeal abscesses. | journal=Curr Infect Dis Rep | year= 2006 | volume= 8 | issue= 3 | pages= 196-202 | pmid=16643771 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16643771 }} </ref>
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| *1. It is proposed to arise from an extension of [[exudative]] [[tonsillitis]].
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| Some authorities believe that blockage of drainage from tonsillar crypt in [[acute]] [[tonsillitis]] results in spread of infection into the peritonsillar space.
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| *2. Involvement of Weber's [[gland]] account for the [[abscess]] formation. Some believe that peritonsillar abscess arises from [[infectious]] process involving group of [[salivary glands]] called Weber's glands located in the supratonsillar space.
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| [[Antigenic]] response following any disturbance arising from within the tonsillar crypt [[Mucosal|mucosa]] allows for [[lymphocytic]] interaction. This disruption in the crypt [[epithelium]] may be preceded by [[infectious]] process. [[Invasion]] and [[proliferation]] of the tonsillar crypt by [[infectious]] [[pathogens]] results in localized [[edema]] and influx of [[neutrophils]]. This is clinically seen as [[inflamed]] [[tonsil]] with or without exudation.<ref name=abd>L. Michaels, H.B. Hellquist Ear, nose and throat histopathology (2nd ed.)Springer-Verlag, London (2001), pp. 281–286</ref> Pus accumulation within tissue behind the supratonsillar space leads to tonsillar bulging, [[uvula]] and [[palate]] deviation.
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| ==Causes==
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| Peritonsillar abscess (PTA) usually arises as a complication of an untreated or partially treated episode of [[acute]] [[tonsillitis]]. The infection, in these cases, spreads to the [[peritonsillar]] area (peritonsillitis). This region comprises of loose [[connective tissue]] and is hence susceptible to formation of [[abscess]]. Peritonsilar abscess can also occur ''de novo''.
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| Both [[Aerobic organism|aerobic]] and [[Anaerobic organism|anaerobic]] bacteria can be causative.<ref name="pmid18039418">{{cite journal| author=Megalamani SB, Suria G, Manickam U, Balasubramanian D, Jothimahalingam S| title=Changing trends in bacteriology of peritonsillar abscess. | journal=J Laryngol Otol | year= 2008 | volume= 122 | issue= 9 | pages= 928-30 | pmid=18039418 | doi=10.1017/S0022215107001144 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18039418 }} </ref><ref name="pmid18039418">{{cite journal| author=Megalamani SB, Suria G, Manickam U, Balasubramanian D, Jothimahalingam S| title=Changing trends in bacteriology of peritonsillar abscess. | journal=J Laryngol Otol | year= 2008 | volume= 122 | issue= 9 | pages= 928-30 | pmid=18039418 | doi=10.1017/S0022215107001144 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18039418 }} </ref>
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| ===Life-threatening causes===
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| Life-threatening conditions may result in death or permanent disability within 24 hours if left untreated. Peritonsillar abscess may become a life-threatening condition and must be treated as such irrespective of the cause.<ref name="pmid15573356">{{cite journal| author=Brook I| title=Microbiology and management of peritonsillar, retropharyngeal, and parapharyngeal abscesses. | journal=J Oral Maxillofac Surg | year= 2004 | volume= 62 | issue= 12 | pages= 1545-50 | pmid=15573356 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15573356 }} </ref><ref name="pmid18039418">{{cite journal| author=Megalamani SB, Suria G, Manickam U, Balasubramanian D, Jothimahalingam S| title=Changing trends in bacteriology of peritonsillar abscess. | journal=J Laryngol Otol | year= 2008 | volume= 122 | issue= 9 | pages= 928-30 | pmid=18039418 | doi=10.1017/S0022215107001144 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18039418 }} </ref>
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| ===Most common cause===
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| The most frequent pathogen of peritonsillar abscess is [[Streptococcus pyogenes]].<ref name="pmid15573356">{{cite journal| author=Brook I| title=Microbiology and management of peritonsillar, retropharyngeal, and parapharyngeal abscesses. | journal=J Oral Maxillofac Surg | year= 2004 | volume= 62 | issue= 12 | pages= 1545-50 | pmid=15573356 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15573356 }} </ref><ref name="pmid18039418">{{cite journal| author=Megalamani SB, Suria G, Manickam U, Balasubramanian D, Jothimahalingam S| title=Changing trends in bacteriology of peritonsillar abscess. | journal=J Laryngol Otol | year= 2008 | volume= 122 | issue= 9 | pages= 928-30 | pmid=18039418 | doi=10.1017/S0022215107001144 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18039418 }} </ref><ref name="pmid1875138">{{cite journal| author=Snow DG, Campbell JB, Morgan DW| title=The microbiology of peritonsillar sepsis. | journal=J Laryngol Otol | year= 1991 | volume= 105 | issue= 7 | pages= 553-5 | pmid=1875138 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1875138 }} </ref><ref name="pmid12092281">{{cite journal| author=Matsuda A, Tanaka H, Kanaya T, Kamata K, Hasegawa M| title=Peritonsillar abscess: a study of 724 cases in Japan. | journal=Ear Nose Throat J | year= 2002 | volume= 81 | issue= 6 | pages= 384-9 | pmid=12092281 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12092281 }} </ref>
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| ===Common causes===
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| Some common causes of peritonsillar abscess include:<ref name="pmid15573356">{{cite journal| author=Brook I| title=Microbiology and management of peritonsillar, retropharyngeal, and parapharyngeal abscesses. | journal=J Oral Maxillofac Surg | year= 2004 | volume= 62 | issue= 12 | pages= 1545-50 | pmid=15573356 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15573356 }} </ref><ref name="pmid18039418">{{cite journal| author=Megalamani SB, Suria G, Manickam U, Balasubramanian D, Jothimahalingam S| title=Changing trends in bacteriology of peritonsillar abscess. | journal=J Laryngol Otol | year= 2008 | volume= 122 | issue= 9 | pages= 928-30 | pmid=18039418 | doi=10.1017/S0022215107001144 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18039418 }} </ref>
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| *[[Fusobacterium necrophorum]]
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| *[[Streptococcus milleri]]
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| *[[Staphylococci]]
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| *[[Haemophilus]]
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| *[[Fusobacterium]]
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| *[[Prevotella]]
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| *''[[Acinetobacter spp|Acinetobacter]]'' [[Acinetobacter spp|spp]].
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| *''[[Candida albicans]]''
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| *[[Peptostreptococcus]] spp.
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| *[[Pseudomonas]] spp.
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| *[[Enterobacter]] spp.
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| *[[Klebsiella]]
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| ===Less common causes===
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| Less common causes of peritonsillar abscess include:<ref name="pmid15573356">{{cite journal| author=Brook I| title=Microbiology and management of peritonsillar, retropharyngeal, and parapharyngeal abscesses. | journal=J Oral Maxillofac Surg | year= 2004 | volume= 62 | issue= 12 | pages= 1545-50 | pmid=15573356 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15573356 }} </ref><ref name="pmid18039418">{{cite journal| author=Megalamani SB, Suria G, Manickam U, Balasubramanian D, Jothimahalingam S| title=Changing trends in bacteriology of peritonsillar abscess. | journal=J Laryngol Otol | year= 2008 | volume= 122 | issue= 9 | pages= 928-30 | pmid=18039418 | doi=10.1017/S0022215107001144 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18039418 }} </ref>
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| * [[Porphyromonas]]
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| ==Differentiating Peritonsillar abscess from Other Diseases==
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| {| class="wikitable"
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| !Disease/Variable
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| !Presentation
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| !Causes
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| !Physical exams findings
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| !Age commonly affected
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| !Imaging finding
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| !Treatment
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| |-
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| |[[Peritonsillar abscess]]
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| |Severe [[sore throat]], [[otalgia]] [[fever]], a "hot potato" or muffled voice, [[drooling]], and [[trismus]]<ref name="pmid18246890" />
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| |[[Streptococcus pyogenes|Aerobic and anaerobic]]
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| [[Streptococcus pyogenes|bacteria most common is]]
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| [[Streptococcus pyogenes|Streptococcus]]
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| [[Streptococcus pyogenes|pyogenes]].<ref name="pmid15573356" /><ref name="pmid18039418" /><ref name="pmid1875138" /><ref name="pmid12092281" />
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| |[[Contralateral]] deflection of the uvula,
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| the [[tonsil]] is displaced [[inferiorly]] and [[medially]], tender [[submandibular]] and [[anterior]] [[cervical lymph nodes|cervical lymph nodes,]] [[Tonsillar abscess|tonsillar]] [[hypertrophy]] with likely peritonsillar [[edema]].
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| |The highest occurrence is in adults between 20 to 40 years of age.<ref name="pmid18246890" />
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| |On ultrasound peritonsillar abscess appears as focal irregularly marginated hypoechoic area.<ref name="pmid15635144" /><ref name="pmid1642863" /><ref name="pmid26637999" /><ref name="pmid10435129" /><ref name="pmid15635144" /><ref name="pmid1642863" />
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| |[[Ampicillin-sulbactam|Ampicillin-sulbactam,]] [[Clindamycin]], [[Vancomycin]] or [[Linezolid]]
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| |-
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| |[[Croup]]
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| |Has [[cough]] and [[stridor]] but no [[drooling]]. Others are [[Hoarseness]], [[Difficulty breathing]], symptoms of the [[common cold]], [[Runny nose]], [[Fever]]
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| |[[Parainfluenza virus]]
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| |Suprasternal and [[intercostal]] [[Indrawing|indrawing,]]<ref name="pmid19445760" /> Inspiratory [[stridor]]<ref name="Cherry2008" />, expiratory [[wheezing]],<ref name="Cherry2008" /> [[Sternal]] wall retractions<ref name="pmid194457602" />
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| |Mainly 6 months and 3 years old
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| rarely, adolescents and adults<ref name="pmid8769531" />
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| |[[Steeple sign]] on neck X-ray
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| |[[Dexamethasone]] and nebulised [[epenephrine|epinephrine]]
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| |-
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| |[[Epiglottitis]]
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| |Has [[stridor]] and [[drooling]] [[Difficulty breathing|but no cough. Other symptoms include difficulty breathing]], [[Difficulty swallowing|fever, chills, difficulty swallowing]], [[hoarseness]] of voice
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| |[[Hemolysis|H. influenza type b,]]
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| [[Hemolysis|beta-hemolytic]] [[streptococci]], ''[[Staphylococcus aureus]],''
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| [[fungi]] and [[viruses]].
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| |[[Cyanosis]], [[Cervical]] [[lymphadenopathy]], Inflammed [[epiglottis]]
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| |Used to be mostly found in
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| pediatric age group between 3 to 5 years,
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| however, recent trend favors adults
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| as most commonly affected individuals<ref name="pmid270310102" />
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| with a mean age of 44.94 years
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| |[[Thumbprint sign]] on neck x-ray
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| |Airway maintenance, p[[Parenteral|arenteral]] [[Cefotaxime]] or [[Ceftriaxone]] in combination with [[Vancomycin]]. Adjuvant therapy includes [[corticosteroids]] and [[racemic]] [[Epinephrine]].<ref name="pmid15983574" /><ref name="pmid12557859" />
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| |-
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| |[[Pharyngitis]]
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| |[[Sore throat]], pain on swallowing, [[fever]], [[headache]], [[Abdominal pain|abdominal]] pain, [[nausea]] and [[vomiting]]
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| |[[Group A beta-hemolytic streptococci|Group A beta-hemolytic]]
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| [[Group A beta-hemolytic streptococci|streptococcus]].
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| |Inflammed [[pharynx]] with or without [[exudate]]
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| |Mostly in children and young adults,
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| with 50% of cases identified
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| between the ages of 5 to 24 years.<ref name=":0" />
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| |_
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| |[[Antimicrobial]] therapy mainly [[penicillin]]-based and [[analgesics]].
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| |-
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| |[[Tonsilitis]]
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| |[[Sore throat]], pain on swallowing, [[fever]], [[headache]], [[cough]]
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| |Most common cause is
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| viral including [[adenovirus]],
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| [[rhinovirus]], [[influenza]],
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| [[coronavirus]], and
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| [[respiratory syncytial virus]].
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| Second most common
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| causes are bacterial;
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| ''[[Group A streptococcal infection|Group A streptococcal]]''
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| ''[[Group A streptococcal infection|bacteria]]'',<ref name="pmid3601520" />
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| |[[Fever]], especially 100°F or higher.<ref name="Tonsillitis" /><ref name="urlTonsillitis - NHS Choices" />[[Erythema]], [[edema]] and [[Exudate]] of the [[tonsils]].<ref name="pmid25587367" /> cervical [[lymphadenopathy]], [[Dysphonia]].<ref name="urlTonsillitis - Symptoms - NHS Choices" />
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| |Primarily affects children
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| between 5 and 15 years old.<ref name="Oroface" />
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| |Intraoral or transcutaneous USG may show an abscess making CT scan unnecessary.<ref name="pmid26527518" /><ref name="pmid25946659" /><ref name="pmid25945805" />
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| |[[Antimicrobial]] therapy mainly [[penicillin]]-based and [[analgesics]] with [[tonsilectomy]] in selected cases.
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| |-
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| |[[Retropharyngeal abscess]]
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| |[[Neck pain]], [[stiff neck]], [[torticollis]]
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| [[fever]], [[malaise]], [[stridor]], and barking [[cough]]
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| |Polymicrobial infection.
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| Mostly; [[Streptococcus pyogenes|Streptococcus]]
| |
| | |
| [[Streptococcus pyogenes|pyogenes]], [[Staphylococcus aureus]] and respiratory anaerobes (example; Fusobacteria, [[Prevotella species|Prevotella]],
| |
| | |
| and Veillonella species)<ref name="pmid23520072" /><ref name="pmid22481424" /><ref name="pmid18948832" /><ref name="pmid15573356" /><ref name="pmid18427007" /><ref name="pmid2235179" />
| |
| |Child may be unable to open the mouth widely. May have enlarged
| |
| [[cervical]] [[lymph nodes]] and neck mass.
| |
| |Mostly between 2-4 years, but can occur in other age groups.<ref name="pmid12777558" /><ref name="pmid1876473" />
| |
| |On CT scan, a mass impinging on the posterior pharyngeal wall with rim enhancement is seen<ref name="pmid15667676" /><ref name="pmid12761699" />
| |
| |Immediate surgical drainage and antimicrobial therapy. emperic therapy involves; [[ampicillin]]-[[sulbactam]] or [[clindamycin]].
| |
| |}
| |
| | |
| ==Epidemiology and Demographics==
| |
| ===Prevalence and incidence===
| |
| The incidence of peritonsillar abscess is highest between November to December and April to May in the northern hemisphere. This has been associated with the highest rates of streptococcal pharyngitis and [[exudative]] [[tonsillitis]] around that these times.<ref name="pmid16448878">{{cite journal| author=Belleza WG, Kalman S| title=Otolaryngologic emergencies in the outpatient setting. | journal=Med Clin North Am | year= 2006 | volume= 90 | issue= 2 | pages= 329-53 | pmid=16448878 | doi=10.1016/j.mcna.2005.12.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16448878 }} </ref><ref name="pmid12087516">{{cite journal| author=Bisno AL, Gerber MA, Gwaltney JM, Kaplan EL, Schwartz RH, Infectious Diseases Society of America| title=Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2002 | volume= 35 | issue= 2 | pages= 113-25 | pmid=12087516 | doi=10.1086/340949 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12087516 }} </ref>
| |
| | |
| ===Age===
| |
| Peritonsillar abscess occur in all age groups. The highest occurrence is in adults between 20 to 40 years of age.<ref name="pmid18246890">{{cite journal| author=Galioto NJ| title=Peritonsillar abscess. | journal=Am Fam Physician | year= 2008 | volume= 77 | issue= 2 | pages= 199-202 | pmid=18246890 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18246890 }} </ref><ref name="pmid11804446">{{cite journal| author=Steyer TE| title=Peritonsillar abscess: diagnosis and treatment. | journal=Am Fam Physician | year= 2002 | volume= 65 | issue= 1 | pages= 93-6 | pmid=11804446 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11804446 }} </ref><ref name="pmid16041198">{{cite journal| author=Khayr W, Taepke J| title=Management of peritonsillar abscess: needle aspiration versus incision and drainage versus tonsillectomy. | journal=Am J Ther | year= 2005 | volume= 12 | issue= 4 | pages= 344-50 | pmid=16041198 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16041198 }} </ref>
| |
| | |
| ===Race===
| |
| There is no racial predilection to developing peritonsillar abscess.
| |
| | |
| ===Gender===
| |
| Males are more commonly affected with peritonsillar abscess than female with male to female ratio of approximately 1.4:1. However, equal male to female ratios have been reported in some studies as well.<ref name="pmid15029410">{{cite journal| author=Ong YK, Goh YH, Lee YL| title=Peritonsillar infections: local experience. | journal=Singapore Med J | year= 2004 | volume= 45 | issue= 3 | pages= 105-9 | pmid=15029410 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15029410 }} </ref><ref name="pmid20015734">{{cite journal| author=Marom T, Cinamon U, Itskoviz D, Roth Y| title=Changing trends of peritonsillar abscess. | journal=Am J Otolaryngol | year= 2010 | volume= 31 | issue= 3 | pages= 162-7 | pmid=20015734 | doi=10.1016/j.amjoto.2008.12.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20015734 }} </ref><ref name="pmid24474247">{{cite journal| author=Klug TE| title=Incidence and microbiology of peritonsillar abscess: the influence of season, age, and gender. | journal=Eur J Clin Microbiol Infect Dis | year= 2014 | volume= 33 | issue= 7 | pages= 1163-7 | pmid=24474247 | doi=10.1007/s10096-014-2052-8 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24474247 }} </ref><ref name="pmid18612664">{{cite journal| author=Gavriel H, Lazarovitch T, Pomortsev A, Eviatar E| title=Variations in the microbiology of peritonsillar abscess. | journal=Eur J Clin Microbiol Infect Dis | year= 2009 | volume= 28 | issue= 1 | pages= 27-31 | pmid=18612664 | doi=10.1007/s10096-008-0583-6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18612664 }} </ref><ref name="pmid19086341">{{cite journal| author=Sunnergren O, Swanberg J, Mölstad S| title=Incidence, microbiology and clinical history of peritonsillar abscesses. | journal=Scand J Infect Dis | year= 2008 | volume= 40 | issue= 9 | pages= 752-5 | pmid=19086341 | doi=10.1080/00365540802040562 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19086341 }} </ref><ref name="pmid21086007">{{cite journal| author=Hidaka H, Kuriyama S, Yano H, Tsuji I, Kobayashi T| title=Precipitating factors in the pathogenesis of peritonsillar abscess and bacteriological significance of the Streptococcus milleri group. | journal=Eur J Clin Microbiol Infect Dis | year= 2011 | volume= 30 | issue= 4 | pages= 527-32 | pmid=21086007 | doi=10.1007/s10096-010-1114-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21086007 }} </ref><ref name="pmid22425204">{{cite journal| author=Costales-Marcos M, López-Álvarez F, Núñez-Batalla F, Moreno-Galindo C, Alvarez Marcos C, Llorente-Pendás JL| title=[Peritonsillar infections: prospective study of 100 consecutive cases]. | journal=Acta Otorrinolaringol Esp | year= 2012 | volume= 63 | issue= 3 | pages= 212-7 | pmid=22425204 | doi=10.1016/j.otorri.2012.01.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22425204 }} </ref>
| |
| | |
| ===Developed and developing countries===
| |
| Peritonsillar abscess has not been found to vary significantly among countries.
| |
| | |
| ==Risk Factors==
| |
| Common risk factors in the development of peritonsillar abscess include:<ref name="pmid16142623">{{cite journal| author=Lehnerdt G, Senska K, Fischer M, Jahnke K| title=[Smoking promotes the formation of peritonsillar abscesses]. | journal=Laryngorhinootologie | year= 2005 | volume= 84 | issue= 9 | pages= 676-9 | pmid=16142623 | doi=10.1055/s-2005-870289 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16142623 }} </ref><ref name="pmid1351238">{{cite journal| author=Dilkes MG, Dilkes JE, Ghufoor K| title=Smoking and quinsy. | journal=Lancet | year= 1992 | volume= 339 | issue= 8808 | pages= 1552 | pmid=1351238 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1351238 }} </ref>
| |
| * [[Smoking]]
| |
| *Previous peritonsillar abscess episodes
| |
| *History of recurrent pharyngotonsillitis
| |
| *Poor [[oral hygiene]]
| |
| | |
| ==Screening==
| |
| There are no screening recommendations for peritonsillar abscess.
| |
| | |
| ==Natural History, Complications, and Prognosis==
| |
| | |
| ===Natural history===
| |
| Peritonsillar abscess if left untreated may result in extraperitonsillar extension.<ref name="pmid25255362">{{cite journal| author=Coughlin AM, Baugh RF, Pine HS| title=Lingual tonsil abscess with parapharyngeal extension: a case report. | journal=Ear Nose Throat J | year= 2014 | volume= 93 | issue= 9 | pages= E7-8 | pmid=25255362 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25255362 }} </ref><ref name="pmid26591220">{{cite journal| author=Deeva YV| title=[SURGICAL TREATMENT OF TONSILLAR NECK PHLEGMON]. | journal=Klin Khir | year= 2015 | volume= | issue= 7 | pages= 47-8 | pmid=26591220 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26591220 }} </ref>
| |
|
| |
| ===Complications===
| |
| The following are some complications that may follow peritonsillar abscess:<ref name="pmid18246890">{{cite journal| author=Galioto NJ| title=Peritonsillar abscess. | journal=Am Fam Physician | year= 2008 | volume= 77 | issue= 2 | pages= 199-202 | pmid=18246890 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18246890 }} </ref><ref name="pmid9231089">{{cite journal| author=Goldenberg D, Golz A, Joachims HZ| title=Retropharyngeal abscess: a clinical review. | journal=J Laryngol Otol | year= 1997 | volume= 111 | issue= 6 | pages= 546-50 | pmid=9231089 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9231089 }} </ref><ref name="pmid2355414">{{cite journal| author=Stevens HE| title=Vascular complication of neck space infection: case report and literature review. | journal=J Otolaryngol | year= 1990 | volume= 19 | issue= 3 | pages= 206-10 | pmid=2355414 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2355414 }} </ref><ref name="pmid7857015">{{cite journal| author=Greinwald JH, Wilson JF, Haggerty PG| title=Peritonsillar abscess: an unlikely cause of necrotizing fasciitis. | journal=Ann Otol Rhinol Laryngol | year= 1995 | volume= 104 | issue= 2 | pages= 133-7 | pmid=7857015 | doi=10.1177/000348949510400209 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7857015 }} </ref><ref name="pmid6594557">{{cite journal| author=Wenig BL, Shikowitz MJ, Abramson AL| title=Necrotizing fasciitis as a lethal complication of peritonsillar abscess. | journal=Laryngoscope | year= 1984 | volume= 94 | issue= 12 Pt 1 | pages= 1576-9 | pmid=6594557 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6594557 }} </ref>
| |
| | |
| *Extraperitonsillar spread example [[Parapharyngeal space infection|parapharyngeal]] extension, deep neck tissues and [[posterior]] [[mediastinum]]<ref name="pmid25255362">{{cite journal| author=Coughlin AM, Baugh RF, Pine HS| title=Lingual tonsil abscess with parapharyngeal extension: a case report. | journal=Ear Nose Throat J | year= 2014 | volume= 93 | issue= 9 | pages= E7-8 | pmid=25255362 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25255362 }} </ref><ref name="pmid26591220">{{cite journal| author=Deeva YV| title=[SURGICAL TREATMENT OF TONSILLAR NECK PHLEGMON]. | journal=Klin Khir | year= 2015 | volume= | issue= 7 | pages= 47-8 | pmid=26591220 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26591220 }} </ref><ref name="pmid26527518">{{cite journal| author=Kawabata M, Umakoshi M, Makise T, Miyashita K, Harada M, Nagano H et al.| title=Clinical classification of peritonsillar abscess based on CT and indications for immediate abscess tonsillectomy. | journal=Auris Nasus Larynx | year= 2016 | volume= 43 | issue= 2 | pages= 182-6 | pmid=26527518 | doi=10.1016/j.anl.2015.09.014 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26527518 }} </ref>
| |
| Peritonsillar abscess may spread through the deep fascia of the neck with associated rapid progression to a more serious infection.
| |
| *Airway obstruction
| |
| *[[Aspiration]] [[pneumonitis]] or lung abscess secondary to peritonsillar abscess rupture
| |
| *[[Hemorrhage]] from erosion or septic [[necrosis]] into [[carotid]] sheath
| |
| *[[Mediastinitis]]
| |
| *Poststreptococcal sequelae (e.g., [[glomerulonephritis]], [[rheumatic fever]]) when infection is caused by [[Group A streptococcus]]
| |
| *[[Necrotizing fasciitis]]
| |
| | |
| ===Prognosis===
| |
| The prognosis of peritonsillar abscess is good with early and appropriate treatment.<ref name="pmid22321140">{{cite journal| author=Powell J, Wilson JA| title=An evidence-based review of peritonsillar abscess. | journal=Clin Otolaryngol | year= 2012 | volume= 37 | issue= 2 | pages= 136-45 | pmid=22321140 | doi=10.1111/j.1749-4486.2012.02452.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22321140 }} </ref><ref name="pmid7782170">{{cite journal| author=Apostolopoulos NJ, Nikolopoulos TP, Bairamis TN| title=Peritonsillar abscess in children. Is incision and drainage an effective management? | journal=Int J Pediatr Otorhinolaryngol | year= 1995 | volume= 31 | issue= 2-3 | pages= 129-35 | pmid=7782170 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7782170 }} </ref><ref name="pmid12646835">{{cite journal| author=Johnson RF, Stewart MG, Wright CC| title=An evidence-based review of the treatment of peritonsillar abscess. | journal=Otolaryngol Head Neck Surg | year= 2003 | volume= 128 | issue= 3 | pages= 332-43 | pmid=12646835 | doi=10.1067/mhn.2003.93 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12646835 }} </ref><ref name="pmid7630308">{{cite journal| author=Herzon FS| title=Harris P. Mosher Award thesis. Peritonsillar abscess: incidence, current management practices, and a proposal for treatment guidelines. | journal=Laryngoscope | year= 1995 | volume= 105 | issue= 8 Pt 3 Suppl 74 | pages= 1-17 | pmid=7630308 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7630308 }} </ref>
| |
|
| |
|
| ==Diagnosis== | | ==Diagnosis== |
| | | [[Peritonsillar abscess history and symptoms|History and Symptoms]] | [[Peritonsillar abscess physical examination|Physical Examination]] | [[Peritonsillar abscess laboratory findings|Laboratory Findings]] | [[Peritonsillar abscess x rays|X Rays]] | [[Peritonsillar abscess other imaging findings|Other Imaging Findings]] | [[Peritonsillar abscess other diagnostic studies|Other Diagnostic Studies]] |
| ===History and Symptoms===
| |
| | |
| * Unlike [[tonsillitis]], which is more common in the pediatric age group, peritonsillar abscess has a more even age spread — from children to adults.
| |
| | |
| * Symptoms start appearing 2-8 days before the formation of [[abscess]]. Common symptoms are:<ref name="pmid18246890">{{cite journal| author=Galioto NJ| title=Peritonsillar abscess. | journal=Am Fam Physician | year= 2008 | volume= 77 | issue= 2 | pages= 199-202 | pmid=18246890 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18246890 }} </ref>
| |
| | |
| :*[[Drooling]]
| |
| :*[[Dysphagia]]
| |
| :*Foul smelling breath
| |
| :*[[Fever]]
| |
| :*[[Headache]]
| |
| :*[[Hoarseness]], muffled voice (also called ''hot potato voice'')
| |
| :*[[Odynophagia]]
| |
| :*[[Otalgia]] (on the side of the abscess)
| |
| :*[[Sore throat]] ( may be severe and unilateral)
| |
| :*[[Stridor]]<ref>{{cite book | last = Ferri | first = Fred | title = Ferri's clinical advisor 2015 : 5 books in 1 | publisher = Elsevier/Mosby | location = Philadelphia, PA | year = 2015 | isbn = 978-0323083751 }}</ref>
| |
| :*[[Malaise]]
| |
| | |
| ===Physical Examination===
| |
| Physical examination findings suggestive of peritonsillar abscess include the following:<ref name="pmid18246890">{{cite journal| author=Galioto NJ| title=Peritonsillar abscess. | journal=Am Fam Physician | year= 2008 | volume= 77 | issue= 2 | pages= 199-202 | pmid=18246890 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18246890 }} </ref><ref>{{cite book | last = Ferri | first = Fred | title = Ferri's clinical advisor 2015 : 5 books in 1 | publisher = Elsevier/Mosby | location = Philadelphia, PA | year = 2015 | isbn = 978-0323083751 }}</ref><ref name="pmid8302122">{{cite journal| author=Passy V| title=Pathogenesis of peritonsillar abscess. | journal=Laryngoscope | year= 1994 | volume= 104 | issue= 2 | pages= 185-90 | pmid=8302122 | doi=10.1288/00005537-199402000-00011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8302122 }} </ref><ref name="pmid11127146">{{cite journal| author=Nwe TT, Singh B| title=Management of pain in peritonsillar abscess. | journal=J Laryngol Otol | year= 2000 | volume= 114 | issue= 10 | pages= 765-7 | pmid=11127146 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11127146 }} </ref>
| |
| | |
| ====Appearance of the Patient====
| |
| * They are usually acutely-ill looking.
| |
| | |
| ====Vital Signs====
| |
| * High [[temperature]]
| |
| | |
| ====HEENT====
| |
| *Muffled voice (also called "hot potato voice")
| |
| * [[Contralateral]] deflection of the uvula
| |
| *The [[tonsil]] is generally displaced [[inferiorly]] and [[medially]]
| |
| * Facial swelling
| |
| * [[Tonsillar abscess|Tonsillar]] [[hypertrophy]] with likely Peritonsillar [[edema]].
| |
| * [[Trismus]]
| |
| * [[Drooling]]
| |
| * [[Rancidification|Rancid]] or [[Fetor oris|fetor]] breath
| |
| | |
| ====Neck====
| |
| * [[Tenderness]] of [[anterior]] neck
| |
| * Tender [[submandibular]] and [[anterior]] [[cervical lymph nodes]]
| |
| | |
| ====Lungs====
| |
| * May be in obvious respiratory distress with flaring of ala nasi, subcostal and intercostal recessions.
| |
| * Increased respiratory rate in both children and adults
| |
| * Decreased air-entry depending of degree of airway obstruction
| |
| | |
| ====Extremities====
| |
| * Cyanosis
| |
| | |
| ===Laboratory Findings===
| |
| Although the diagnosis of peritonsillar abscess may be made without the use of laboratory findings, the following nonspecific laboratory findings may be seen:<ref name="pmid23612569">{{cite journal| author=Powell EL, Powell J, Samuel JR, Wilson JA| title=A review of the pathogenesis of adult peritonsillar abscess: time for a re-evaluation. | journal=J Antimicrob Chemother | year= 2013 | volume= 68 | issue= 9 | pages= 1941-50 | pmid=23612569 | doi=10.1093/jac/dkt128 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23612569 }} </ref><ref name=abd>L. Michaels, H.B. Hellquist Ear, nose and throat histopathology (2nd ed.)Springer-Verlag, London (2001), pp. 281–286</ref><ref name="pmid8302122">{{cite journal| author=Passy V| title=Pathogenesis of peritonsillar abscess. | journal=Laryngoscope | year= 1994 | volume= 104 | issue= 2 | pages= 185-90 | pmid=8302122 | doi=10.1288/00005537-199402000-00011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8302122 }} </ref><ref name="pmid25865201">{{cite journal| author=Blair AB, Booth R, Baugh R| title=A unifying theory of tonsillitis, intratonsillar abscess and peritonsillar abscess. | journal=Am J Otolaryngol | year= 2015 | volume= 36 | issue= 4 | pages= 517-20 | pmid=25865201 | doi=10.1016/j.amjoto.2015.03.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25865201 }} </ref><ref name="pmid16643771">{{cite journal| author=Herzon FS, Martin AD| title=Medical and surgical treatment of peritonsillar, retropharyngeal, and parapharyngeal abscesses. | journal=Curr Infect Dis Rep | year= 2006 | volume= 8 | issue= 3 | pages= 196-202 | pmid=16643771 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16643771 }} </ref>
| |
| | |
| *[[Complete blood count]] with differential
| |
| | |
| :*This usually shows [[leukocytosis]] with neutrophilic predominance
| |
| | |
| *Serum [[Electrolyte|electrolytes]]
| |
| :*This is useful too in patients presenting with [[dehydration]]
| |
| | |
| *[[Gram stain]], culture and sensitivity for sample after abscess drainage.
| |
| :*Emperic therapy should be initiated and modified accordingly when results are ready.
| |
| | |
| *A routine [[throat culture]] for [[group A streptococcus]].
| |
| | |
| ===Imaging Findings===
| |
| The diagnosis of peritonsillar abscess may be made without the use of imaging however, imaging options may help in differentiating peritonsillar abscess from other simialr conditions example, peritonsillar cellulitis, retropharyngeal abscess and epiglottitis.
| |
| | |
| ====Ultrasound====
| |
| This is helpful in differentiating peritonsillar abscess from peritonsillar cellulitis as well as a guide during abscess drainage.
| |
| The approach may be intraoral or submandibular.<ref name="pmid22687177">{{cite journal| author=Costantino TG, Satz WA, Dehnkamp W, Goett H| title=Randomized trial comparing intraoral ultrasound to landmark-based needle aspiration in patients with suspected peritonsillar abscess. | journal=Acad Emerg Med | year= 2012 | volume= 19 | issue= 6 | pages= 626-31 | pmid=22687177 | doi=10.1111/j.1553-2712.2012.01380.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22687177 }} </ref><ref name="pmid26637999">{{cite journal| author=Bandarkar AN, Adeyiga AO, Fordham MT, Preciado D, Reilly BK| title=Tonsil ultrasound: technical approach and spectrum of pediatric peritonsillar infections. | journal=Pediatr Radiol | year= 2016 | volume= 46 | issue= 7 | pages= 1059-67 | pmid=26637999 | doi=10.1007/s00247-015-3505-7 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26637999 }} </ref><ref name="pmid8141026">{{cite journal| author=Buckley AR, Moss EH, Blokmanis A| title=Diagnosis of peritonsillar abscess: value of intraoral sonography. | journal=AJR Am J Roentgenol | year= 1994 | volume= 162 | issue= 4 | pages= 961-4 | pmid=8141026 | doi=10.2214/ajr.162.4.8141026 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8141026 }} </ref><ref name="pmid7630286">{{cite journal| author=Strong EB, Woodward PJ, Johnson LP| title=Intraoral ultrasound evaluation of peritonsillar abscess. | journal=Laryngoscope | year= 1995 | volume= 105 | issue= 8 Pt 1 | pages= 779-82 | pmid=7630286 | doi=10.1288/00005537-199508000-00002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7630286 }} </ref><ref name="pmid12671820">{{cite journal| author=Blaivas M, Theodoro D, Duggal S| title=Ultrasound-guided drainage of peritonsillar abscess by the emergency physician. | journal=Am J Emerg Med | year= 2003 | volume= 21 | issue= 2 | pages= 155-8 | pmid=12671820 | doi=10.1053/ajem.2003.50029 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12671820 }} </ref>
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| On ultrasound the following may be found:<ref name="pmid15635144">{{cite journal| author=Lyon M, Blaivas M| title=Intraoral ultrasound in the diagnosis and treatment of suspected peritonsillar abscess in the emergency department. | journal=Acad Emerg Med | year= 2005 | volume= 12 | issue= 1 | pages= 85-8 | pmid=15635144 | doi=10.1197/j.aem.2004.08.045 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15635144 }} </ref><ref name="pmid1642863">{{cite journal| author=Boesen T, Jensen F| title=Preoperative ultrasonographic verification of peritonsillar abscesses in patients with severe tonsillitis. | journal=Eur Arch Otorhinolaryngol | year= 1992 | volume= 249 | issue= 3 | pages= 131-3 | pmid=1642863 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1642863 }} </ref><ref name="pmid26637999">{{cite journal| author=Bandarkar AN, Adeyiga AO, Fordham MT, Preciado D, Reilly BK| title=Tonsil ultrasound: technical approach and spectrum of pediatric peritonsillar infections. | journal=Pediatr Radiol | year= 2016 | volume= 46 | issue= 7 | pages= 1059-67 | pmid=26637999 | doi=10.1007/s00247-015-3505-7 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26637999 }} </ref><ref name="pmid10435129">{{cite journal| author=Scott PM, Loftus WK, Kew J, Ahuja A, Yue V, van Hasselt CA| title=Diagnosis of peritonsillar infections: a prospective study of ultrasound, computerized tomography and clinical diagnosis. | journal=J Laryngol Otol | year= 1999 | volume= 113 | issue= 3 | pages= 229-32 | pmid=10435129 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10435129 }} </ref><ref name="pmid15635144">{{cite journal| author=Lyon M, Blaivas M| title=Intraoral ultrasound in the diagnosis and treatment of suspected peritonsillar abscess in the emergency department. | journal=Acad Emerg Med | year= 2005 | volume= 12 | issue= 1 | pages= 85-8 | pmid=15635144 | doi=10.1197/j.aem.2004.08.045 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15635144 }} </ref><ref name="pmid1642863">{{cite journal| author=Boesen T, Jensen F| title=Preoperative ultrasonographic verification of peritonsillar abscesses in patients with severe tonsillitis. | journal=Eur Arch Otorhinolaryngol | year= 1992 | volume= 249 | issue= 3 | pages= 131-3 | pmid=1642863 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1642863 }} </ref>
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| *Peritonsillar abscess appears as focal irregularly marginated hypoechoic area.
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| *Irregular hypoechoic areas within the tonsil may represent pockets of developing purulence or necrosis called intratonsillar abscesses.
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| *Peritonsillar cellulitis appears as enlarged tonsil (arrows) with ill-defined margins and markedly increased echogenicity of surrounding soft tissues that suggests significant inflammatory change/cellulitis.
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| ====CT scan====
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| Coronal contrast-enhanced CT scan of the neck may identify the peritonsillar abscess.<ref name="pmid26637999">{{cite journal| author=Bandarkar AN, Adeyiga AO, Fordham MT, Preciado D, Reilly BK| title=Tonsil ultrasound: technical approach and spectrum of pediatric peritonsillar infections. | journal=Pediatr Radiol | year= 2016 | volume= 46 | issue= 7 | pages= 1059-67 | pmid=26637999 | doi=10.1007/s00247-015-3505-7 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26637999 }} </ref>
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| ==Treatment== | | ==Treatment== |
| ===Medical Therapy===
| | [[Peritonsillar abscess medical therapy|Medical Therapy]] | [[Peritonsillar abscess primary prevention|Primary Prevention]] | [[Peritonsillar abscess secondary prevention|Secondary Prevention]] |
| Parenteral therapy is the preferred first line route of administration until the temperature of the patient has settled and clinically improved and then switched to oral therapy to complete a 14-day course.<ref name="pmid7782170">{{cite journal| author=Apostolopoulos NJ, Nikolopoulos TP, Bairamis TN| title=Peritonsillar abscess in children. Is incision and drainage an effective management? | journal=Int J Pediatr Otorhinolaryngol | year= 1995 | volume= 31 | issue= 2-3 | pages= 129-35 | pmid=7782170 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7782170 }} </ref>
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| ====Antimicrobial Regimen==== | | ==Case Studies== |
| Below are the antimicrobial regimen available in treating peritonsillar abscess.<ref name=abc>Principles and Practice of Pediatric Infectious Diseases, 4th ed, Long SS, Pickering LK, Prober CG (Eds), Elsevier Saunders, New York 2012. p.205.</ref>
| | [[Peritonsillar abscess case study one|Case #1]] |
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| :::* Preferred regimen in adults: [[Ampicillin-sulbactam]] 3 g IV 6h
| | {{Respiratory pathology}} |
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| :::* Preferred regimen in children: [[Ampicillin-sulbactam]] 50 mg/kg per dose [maximum single dose 3 g] IV 6h
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| :::* Alternative regimen in adults: [[Clindamycin]] 600mg IV 6-8h
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| :::* Alternative regimen in children: [[Clindamycin]] 13 mg/kg per dose [maximum single dose 900 mg] IV 8h
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| The above alternative therapy are employed in the following situations:
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| *Patients not improving on [[Ampicillin-Sulbactam|Ampicillin-sulbactam]] or [[Clindamycin]]
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| *Severe infection presenting with;
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| **Toxic appearance,
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| **Temperature >39°C,
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| **[[Drooling]], and/or [[respiratory distress]])
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| '''Pathogen-directed antimicrobial therapy'''
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| *'''Resistant Gram-positive cocci'''
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| For resistant Gram-positive cocci infections IV [[Vancomycin]] or [[Linezolid]] is added to the above emperic therapy.
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| ===Surgery===
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| Surgical modalities in the management of peritonsillar abscess involve the use of the following:
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| *[[Incision and drainage]], or
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| *[[Tonsillectomy]]
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| ====Indications for [[tonsillectomy]] in peritonsillar abscess====
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| *Severe upper respirtaory obstruction
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| *Previous episodes of severe recurrent [[pharyngitis]] or peritonsillar abscess
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| *Unresolving peritonsillar abscess after antibiotics [[incision and drainage]]
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| ==Prevention==
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| There are no definite preventive measures for peritonsillar abscess, however, immunization against certain organisms in chikdhood may decrease the burden of peritonsillar abscess resulting from such infections.
| |
| *[[Immunization]] with the [[Hib]] vaccine protects children.<ref name="pmid18931398">{{cite journal| author=Mathoera RB, Wever PC, van Dorsten FR, Balter SG, de Jager CP| title=Epiglottitis in the adult patient. | journal=Neth J Med | year= 2008 | volume= 66 | issue= 9 | pages= 373-7 | pmid=18931398 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18931398 }} </ref>
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| *In the United states, [[vaccination]] against [[Haemophilus influenzae infection|Hib]] in children was initiated in the 1980s. Immunity against Hib has been adequate with an increasing level of [[immunization]] among children.
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| * Post-[[splenectomy]] patients are also recommended to be immunized.<ref name="pmid18931398">{{cite journal| author=Mathoera RB, Wever PC, van Dorsten FR, Balter SG, de Jager CP| title=Epiglottitis in the adult patient. | journal=Neth J Med | year= 2008 | volume= 66 | issue= 9 | pages= 373-7 | pmid=18931398 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18931398 }} </ref>
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| ==References==
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| {{Reflist|2}}
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| ==External links==
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| *[http://icarus.med.utoronto.ca/carr/manual/pta.html Practical ENT For Primary Care Physicians web site]
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|
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| *[http://www.drtbalu.com/quinsy.html (Detailed description with video clipping)]
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| {{Respiratory pathology}}
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