Peritonsillar abscess differential diagnosis
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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 | 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 | Has stridor and drooling but no cough. Other symptoms include difficulty breathing, fever, chills, difficulty swallowing, hoarseness of voice | H. influenza type b, | Cyanosis, Cervical lymphadenopathy, Inflammed 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 | Inflammed 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, cough | Most common cause is
viral including adenovirus, coronavirus, and Second most common causes are bacterial; |
Fever, especially 100°F or higher.[19][20]Erythema, edema and Exudate of the tonsils.[21] cervical lymphadenopathy, 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 | Polymicrobial infection.
Mostly; Streptococcus pyogenes, Staphylococcus aureus and respiratory anaerobes (example; Fusobacteria, Prevotella, |
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. |