Peritonsillar abscess differential diagnosis: Difference between revisions

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[[Streptococcus pyogenes|pyogenes]].<ref name="pmid15573356" /><ref name="pmid18039418" /><ref name="pmid1875138" /><ref name="pmid12092281" />
[[Streptococcus pyogenes|pyogenes]].<ref name="pmid15573356" /><ref name="pmid18039418" /><ref name="pmid1875138" /><ref name="pmid12092281" />
|[[Contralateral]] deflection of the uvula,
|[[Contralateral]] deflection of the [[uvula]],
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]].
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]].
|The highest occurrence is in adults between 20 to 40 years of age.<ref name="pmid18246890" />
|The highest occurrence is in adults between 20 to 40 years of age.<ref name="pmid18246890" />
Line 36: Line 36:
|Has [[cough]] and [[stridor]] but no [[drooling]]. Others are [[Hoarseness]], [[Difficulty breathing]], symptoms of the [[common cold]], [[Runny nose]], [[Fever]]
|Has [[cough]] and [[stridor]] but no [[drooling]]. Others are [[Hoarseness]], [[Difficulty breathing]], symptoms of the [[common cold]], [[Runny nose]], [[Fever]]
|[[Parainfluenza virus]]
|[[Parainfluenza virus]]
|Suprasternal and [[intercostal]] [[Indrawing|indrawing,]]<ref name="pmid19445760" /> Inspiratory [[stridor]]<ref name="Cherry2008" />, expiratory [[wheezing]],<ref name="Cherry2008" />  [[Sternal]] wall retractions<ref name="pmid194457602" />
|[[Suprasternal notch|Suprasternal]] and [[intercostal]] [[Indrawing|indrawing,]]<ref name="pmid19445760" /> Inspiratory [[stridor]]<ref name="Cherry2008" />, expiratory [[wheezing]],<ref name="Cherry2008" />  [[Sternal]] wall retractions<ref name="pmid194457602" />
|Mainly 6 months and 3 years old
|Mainly 6 months and 3 years old
rarely, adolescents and adults<ref name="pmid8769531" />
rarely, adolescents and adults<ref name="pmid8769531" />
Line 43: Line 43:
|-
|-
|[[Epiglottitis]]
|[[Epiglottitis]]
|Has  [[stridor]] and [[drooling]] [[Difficulty breathing|but no cough. Other symptoms include difficulty breathing]], [[Difficulty swallowing|fever, chills, difficulty swallowing]], [[hoarseness]] of voice
|[[Stridor]] and [[drooling]] [[Difficulty breathing|but no cough. Other symptoms include difficulty breathing]], [[Difficulty swallowing|fever, chills, difficulty swallowing]], [[hoarseness]] of [[voice]]
|[[Hemolysis|H. influenza type b,]]
|[[Hemolysis|H. influenza type b,]]
[[Hemolysis|beta-hemolytic]] [[streptococci]], ''[[Staphylococcus aureus]],''  
[[Hemolysis|beta-hemolytic]] [[streptococci]], ''[[Staphylococcus aureus]],''  


[[fungi]] and [[viruses]].
[[fungi]] and [[viruses]].
|[[Cyanosis]], [[Cervical]] [[lymphadenopathy]], Inflammed [[epiglottis]]
|[[Cyanosis]], [[Cervical]] [[lymphadenopathy]], [[Inflamed]] [[epiglottis]]
|Used to be mostly found in
|Used to be mostly found in
pediatric age group between 3 to 5 years,
pediatric age group between 3 to 5 years,
Line 58: Line 58:
with a mean age of 44.94 years
with a mean age of 44.94 years
|[[Thumbprint sign]] on neck x-ray
|[[Thumbprint sign]] on neck x-ray
|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" />
|[[Airway]] maintenance, [[Parenteral|parenteral]] [[Cefotaxime]] or [[Ceftriaxone]] in combination with [[Vancomycin]]. [[Adjuvant therapy]] includes [[corticosteroids]] and [[racemic]] [[Epinephrine]].<ref name="pmid15983574" /><ref name="pmid12557859" />
|-
|-
|[[Pharyngitis]]
|[[Pharyngitis]]
|[[Sore throat]], pain on swallowing, [[fever]], [[headache]], [[Abdominal pain|abdominal]] pain, [[nausea]] and [[vomiting]]
|[[Sore throat]], pain on swallowing, [[fever]], [[headache]], [[abdominal pain]], [[nausea]] and [[vomiting]]
|[[Group A beta-hemolytic streptococci|Group A beta-hemolytic]]
|[[Group A beta-hemolytic streptococci|Group A beta-hemolytic]]
[[Group A beta-hemolytic streptococci|streptococcus]].
[[Group A beta-hemolytic streptococci|streptococcus]].
|Inflammed [[pharynx]] with or without [[exudate]]
|[[Inflamed]] [[pharynx]] with or without [[exudate]]
|Mostly in children and young adults,
|Mostly in children and young adults,
with 50% of cases identified  
with 50% of cases identified  
Line 73: Line 73:
|-
|-
|[[Tonsilitis]]
|[[Tonsilitis]]
|[[Sore throat]], pain on swallowing, [[fever]], [[headache]], [[cough]]
|[[Sore throat]], pain on swallowing, [[fever]], [[headache]], and [[cough]]
|Most common cause is
|Most common cause is
viral including [[adenovirus]],
[[viral]] including [[adenovirus]],


[[rhinovirus]], [[influenza]],
[[rhinovirus]], [[influenza]],
Line 90: Line 90:


''[[Group A streptococcal infection|bacteria]]'',<ref name="pmid3601520" />
''[[Group A streptococcal infection|bacteria]]'',<ref name="pmid3601520" />
|[[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" />
|[[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]], and  [[Dysphonia]].<ref name="urlTonsillitis - Symptoms - NHS Choices" />
|Primarily affects children
|Primarily affects children
between 5 and 15 years old.<ref name="Oroface" />
between 5 and 15 years old.<ref name="Oroface" />
|Intraoral or transcutaneous USG may show an abscess making CT scan unnecessary.<ref name="pmid26527518" /><ref name="pmid25946659" /><ref name="pmid25945805" />
|Intraoral or transcutaneous USG may show an [[abscess]] making CT scan unnecessary.<ref name="pmid26527518" /><ref name="pmid25946659" /><ref name="pmid25945805" />
|[[Antimicrobial]] therapy mainly [[penicillin]]-based and [[analgesics]] with [[tonsilectomy]] in selected cases.
|[[Antimicrobial]] therapy mainly [[penicillin]]-based and [[analgesics]] with [[tonsilectomy]] in selected cases.
|-
|-
|[[Retropharyngeal abscess]]
|[[Retropharyngeal abscess]]
|[[Neck pain]], [[stiff neck]], [[torticollis]]
|[[Neck pain]], [[stiff neck]], [[torticollis]], [[fever]], [[malaise]], [[stridor]], and barking [[cough]]
[[fever]], [[malaise]], [[stridor]], and barking [[cough]]
|Polymicrobial infection.  
|Polymicrobial infection.  
Mostly; [[Streptococcus pyogenes|Streptococcus]]
Mostly; [[Streptococcus pyogenes|Streptococcus]]


[[Streptococcus pyogenes|pyogenes]], [[Staphylococcus aureus]] and respiratory anaerobes (example; Fusobacteria, [[Prevotella species|Prevotella]],
[[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" />
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
|Child may be unable to open the mouth widely. May have enlarged [[cervical]] [[lymph nodes]] and neck mass.
[[cervical]] [[lymph nodes]] and neck mass.
|Mostly between 2-4 years, but can occur in other age groups.<ref name="pmid12777558" /><ref name="pmid1876473" />
|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" />
|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]].
|Immediate surgical drainage and antimicrobial therapy. emperic therapy involves; [[ampicillin]]-[[sulbactam]] or [[clindamycin]].
|}
|}

Revision as of 19:52, 7 March 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Prince Tano Djan, BSc, MBChB [2]

Overview

Peritonsillar abscess must be differentiated from other upper respiratory diseases and conditions that may cause throat pain and airway obstruction. These include; croup(laryngotracheobronchitis), pharyngitis, tonsilitis, retropharyngeal abscess and epiglottitis.

Differential diagnosis

Peritonsillar abscess must be differentiated from other upper respiratory diseases and conditions that may cause throat pain and airway obstruction as shown in the table below:

Disease/Variable Presentation Causes Physical exams findings Age commonly affected Imaging finding Treatment
Peritonsillar abscess Severe sore throat, otalgia fever, a "hot potato" or muffled voice, drooling, and trismus[1] Aerobic and anaerobic

bacteria most common is

Streptococcus

pyogenes.[2][3][4][5]

Contralateral deflection of the uvula,

the tonsil is displaced inferiorly and medially, tender submandibular and anterior cervical lymph nodes, tonsillar hypertrophy with likely peritonsillar edema.

The highest occurrence is in adults between 20 to 40 years of age.[1] On ultrasound peritonsillar abscess appears as focal irregularly marginated hypoechoic area.[6][7][8][9][6][7] Ampicillin-sulbactam, Clindamycin, Vancomycin or Linezolid
Croup Has cough and stridor but no drooling. Others are Hoarseness, Difficulty breathing, symptoms of the common cold, Runny nose, Fever Parainfluenza virus Suprasternal and intercostal indrawing,[10] Inspiratory stridor[11], expiratory wheezing,[11] Sternal wall retractions[12] Mainly 6 months and 3 years old

rarely, adolescents and adults[13]

Steeple sign on neck X-ray Dexamethasone and nebulised epinephrine
Epiglottitis Stridor and drooling but no cough. Other symptoms include difficulty breathing, fever, chills, difficulty swallowing, hoarseness of voice H. influenza type b,

beta-hemolytic streptococci, Staphylococcus aureus,

fungi and viruses.

Cyanosis, Cervical lymphadenopathy, Inflamed epiglottis Used to be mostly found in

pediatric age group between 3 to 5 years,

however, recent trend favors adults

as most commonly affected individuals[14]

with a mean age of 44.94 years

Thumbprint sign on neck x-ray Airway maintenance, parenteral Cefotaxime or Ceftriaxone in combination with Vancomycin. Adjuvant therapy includes corticosteroids and racemic Epinephrine.[15][16]
Pharyngitis Sore throat, pain on swallowing, fever, headache, abdominal pain, nausea and vomiting Group A beta-hemolytic

streptococcus.

Inflamed pharynx with or without exudate Mostly in children and young adults,

with 50% of cases identified

between the ages of 5 to 24 years.[17]

_ Antimicrobial therapy mainly penicillin-based and analgesics.
Tonsilitis Sore throat, pain on swallowing, fever, headache, and cough Most common cause is

viral including adenovirus,

rhinovirus, influenza,

coronavirus, and

respiratory syncytial virus.

Second most common

causes are bacterial;

Group A streptococcal

bacteria,[18]

Fever, especially 100°F or higher.[19][20]Erythema, edema and exudate of the tonsils,[21] cervical lymphadenopathy, and Dysphonia.[22] Primarily affects children

between 5 and 15 years old.[23]

Intraoral or transcutaneous USG may show an abscess making CT scan unnecessary.[24][25][26] Antimicrobial therapy mainly penicillin-based and analgesics with tonsilectomy in selected cases.
Retropharyngeal abscess Neck pain, stiff neck, torticollis, fever, malaise, stridor, and barking cough Polymicrobial infection.

Mostly; Streptococcus

pyogenes, Staphylococcus aureus and respiratory anaerobes (example; Fusobacteria, Prevotella,

and Veillonella species)[27][28][29][2][30][31]

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.[32][33] On CT scan, a mass impinging on the posterior pharyngeal wall with rim enhancement is seen[34][35] Immediate surgical drainage and antimicrobial therapy. emperic therapy involves; ampicillin-sulbactam or clindamycin.

References

  1. ↑ 1.0 1.1 Invalid <ref> tag; no text was provided for refs named pmid18246890
  2. ↑ 2.0 2.1 Invalid <ref> tag; no text was provided for refs named pmid15573356
  3. ↑ Invalid <ref> tag; no text was provided for refs named pmid18039418
  4. ↑ Invalid <ref> tag; no text was provided for refs named pmid1875138
  5. ↑ Invalid <ref> tag; no text was provided for refs named pmid12092281
  6. ↑ 6.0 6.1 Invalid <ref> tag; no text was provided for refs named pmid15635144
  7. ↑ 7.0 7.1 Invalid <ref> tag; no text was provided for refs named pmid1642863
  8. ↑ Invalid <ref> tag; no text was provided for refs named pmid26637999
  9. ↑ Invalid <ref> tag; no text was provided for refs named pmid10435129
  10. ↑ Invalid <ref> tag; no text was provided for refs named pmid19445760
  11. ↑ 11.0 11.1 Invalid <ref> tag; no text was provided for refs named Cherry2008
  12. ↑ Invalid <ref> tag; no text was provided for refs named pmid194457602
  13. ↑ Invalid <ref> tag; no text was provided for refs named pmid8769531
  14. ↑ Invalid <ref> tag; no text was provided for refs named pmid270310102
  15. ↑ Invalid <ref> tag; no text was provided for refs named pmid15983574
  16. ↑ Invalid <ref> tag; no text was provided for refs named pmid12557859
  17. ↑ Invalid <ref> tag; no text was provided for refs named :0
  18. ↑ Invalid <ref> tag; no text was provided for refs named pmid3601520
  19. ↑ Invalid <ref> tag; no text was provided for refs named Tonsillitis
  20. ↑ Invalid <ref> tag; no text was provided for refs named urlTonsillitis - NHS Choices
  21. ↑ Invalid <ref> tag; no text was provided for refs named pmid25587367
  22. ↑ Invalid <ref> tag; no text was provided for refs named urlTonsillitis - Symptoms - NHS Choices
  23. ↑ Invalid <ref> tag; no text was provided for refs named Oroface
  24. ↑ Invalid <ref> tag; no text was provided for refs named pmid26527518
  25. ↑ Invalid <ref> tag; no text was provided for refs named pmid25946659
  26. ↑ Invalid <ref> tag; no text was provided for refs named pmid25945805
  27. ↑ Invalid <ref> tag; no text was provided for refs named pmid23520072
  28. ↑ Invalid <ref> tag; no text was provided for refs named pmid22481424
  29. ↑ Invalid <ref> tag; no text was provided for refs named pmid18948832
  30. ↑ Invalid <ref> tag; no text was provided for refs named pmid18427007
  31. ↑ Invalid <ref> tag; no text was provided for refs named pmid2235179
  32. ↑ Invalid <ref> tag; no text was provided for refs named pmid12777558
  33. ↑ Invalid <ref> tag; no text was provided for refs named pmid1876473
  34. ↑ Invalid <ref> tag; no text was provided for refs named pmid15667676
  35. ↑ Invalid <ref> tag; no text was provided for refs named pmid12761699

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