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Abses peritonsil

ABSES PERITONSIL

Oleh Taufik Abidin Fakultas Kedokteran Universitas Mataram PENDAHULUAN Abses peritonsiler dapat terjadi pada umur 10-60 tahun, namun paling sering terjadi pada umur 20-40 tahun. Pada anak-anak jarang terjadi kecuali pada mereka yang menurun sistem immunnya, tapi infeksi bisa menyebabkan obstruksi jalan napas yang signifikan pada anak-anak. Infeksi ini memiliki proporsi yang sama antara lakilaki dan perempuan. Bukti menunjukkan bahwa tonsilitis kronik atau percobaan multipel penggunaan antibiotik oral untuk tonsilitis akut merupakan predisposisi pada orang untuk berkembangnya abses peritonsiler. Di Amerika insiden tersebut kadang-kadang berkisar 30 kasus per 100.000 orang per tahun, dipertimbangkan hampir 45.000 kasus setiap tahun4. Abses leher dalam terbentuk dalam ruang potensial diantara fasia leher dalam sebagai akibat dari penjalaran infeksi dari berbagai sumber, seperti gigi, mulut, tenggorok, sinus paranasal, telinga tengah dan leher tergantung ruang mana yang terlibat. Gejala dan tanda klinik dapat berupa nyeri dan pembengkakan. Abses peritonsiler (Quinsy) merupakan salah satu dari Abses leher dalam dimana selain itu abses leher dalam dapat juga abses retrofaring, abses parafaring, abses submanidibula dan angina ludovici (Ludwig Angina) 3. Abses peritonsiler adalah penyakit infeksi yang paling sering terjadi pada bagian kepala dan leher. Gabungan dari bakteri aerobic dan anaerobic di daerah peritonsilar. Tempat yang bisa berpotensi terjadinya abses adalah adalah didaerah pillar tonsil anteroposterior, fossa piriform inferior, dan palatum superior4. Abses peritonsil terbentuk oleh karena penyebaran organisme bakteri penginfeksi tenggorokan kesalah satu ruangan aereolar yang longgar disekitar faring menyebabkan pembentukan abses, dimana infeksi telah menembus kapsul tonsil tetapi tetap dalam batas otot konstriktor faring5.

Peritonsillar

abscess

(PTA)

merupakan

kumpulan/timbunan

(accumulation) pus (nanah) yang terlokalisir/terbatas (localized) pada jaringan peritonsillar yang terbentuk sebagai hasil dari suppurative tonsillitis.

Gambar 1. Anatomi Tonsil Palatina dan jaringan sekitarnya. ETIOLOGI Abses peritonsil terjadi sebagai akibat komplikasi tonsilitis akut atau infeksi yang bersumber dari kelenjar mucus Weber di kutub atas tonsil. Biasanya kuman penyebabnya sama dengan kuman penyebab tonsilitis. Biasanya unilateral dan lebih sering pada anak-anak yang lebih tua dan dewasa muda2. Abses peritonsiler disebabkan oleh organisme yang bersifat aerob maupun yang bersifat anaerob. Organisme aerob yang paling sering menyebabkan abses peritonsiler adalah Streptococcus pyogenes (Group A Beta-hemolitik streptoccus), Staphylococcus aureus, dan Haemophilus influenzae. Sedangkan organisme anaerob yang berperan adalah Fusobacterium. Prevotella, Porphyromonas, Fusobacterium, dan Peptostreptococcus spp. Untuk kebanyakan abses peritonsiler diduga disebabkan karena kombinasi antara organisme aerobik dan anaerobik6. PATOLOGI Patofisiologi PTA belum diketahui sepenuhnya. Namun, teori yang paling banyak diterima adalah kemajuan (progression) episode tonsillitis eksudatif

pertama menjadi peritonsillitis dan kemudian terjadi pembentukan abses yang sebenarnya (frank abscess formation). Daerah superior dan lateral fosa tonsilaris merupakan jaringan ikat longgar, oleh karena itu infiltrasi supurasi ke ruang potensial peritonsil tersering menempati daerah ini, sehingga tampak palatum mole membengkak. Abses peritonsil juga dapat terbentuk di bagian inferior, namun jarang. Pada stadium permulaan, (stadium infiltrat), selain pembengkakan tampak juga permukaan yang hiperemis. Bila proses berlanjut, daerah tersebut lebih lunak dan berwarna kekuning-kuningan. Tonsil terdorong ke tengah, depan, dan bawah, uvula bengkak dan terdorong ke sisi kontra lateral. Bila proses terus berlanjut, peradangan jaringan di sekitarnya akan menyebabkan iritasi pada m.pterigoid interna, sehingga timbul trismus. Abses dapat pecah spontan, sehingga dapat terjadi aspirasi ke paru. Selain itu, PTA terbukti dapat timbul de novo tanpa ada riwayat tonsillitis kronis atau berulang (recurrent) sebelumnya. PTA dapat juga merupakan suatu gambaran (presentation) dari infeksi virus Epstein-Barr (yaitu: mononucleosis). GEJALA KLINIS DAN DIAGNOSIS Selain gejala dan tanda tonsilitis akut, terdapat juga odinofagia (nyeru menelan) yang hebat, biasanya pada sisi yang

sama juga dan nyeri telinga (otalgia), muntah (regurgitasi), mulut berbau (foetor ex ore), banyak ludah (hipersalivasi), suara sengau (rinolalia), dan kadang-kadang sukar membuka mulut (trismus), serta pembengkakan kelenjar submandibula dengan nyeri tekan. Bila ada nyeri di leher (neck pain) dan atau terbatasnya gerakan leher (limitation in neck mobility), maka ini dikarenakan lymphadenopathy dan peradangan otot tengkuk (cervical muscle inflammation)1. Prosedur diagnosis dengan melakukan Aspirasi jarum (needle aspiration). Tempat aspiration dibius / dianestesi menggunakan lidocaine dengan epinephrine dan jarum besar (berukuran 1618) yang biasa menempel pada syringe berukuran 10cc. Aspirasi material yang bernanah (purulent) merupakan tanda khas, dan material dapat dikirim untuk dibiakkan.

Gambar 2. tonsillitis akut (sebelah kiri) dan abses peritonsil (sebelah kanan). Pada penderita PTA perlu dilakukan pemeriksaan7: 1. Hitung darah lengkap (complete blood count), pengukuran kadar elektrolit (electrolyte level measurement), dan kultur darah (blood cultures). 2. Tes Monospot (antibodi heterophile) perlu dilakukan pada pasien dengan tonsillitis dan bilateral cervical lymphadenopathy. Jika hasilnya positif, penderita memerlukan evaluasi/penilaian hepatosplenomegaly. Liver function tests perlu dilakukan pada penderita dengan hepatomegaly. 3. Throat culture atau throat swab and culture: diperlukan untuk identifikasi organisme yang infeksius. Hasilnya dapat digunakan untuk pemilihan antibiotik yang tepat dan efektif, untuk mencegah timbulnya resistensi antibiotik. 4. Plain radiographs: pandangan jaringan lunak lateral (Lateral soft tissue views) dari nasopharynx dan oropharynx dapat membantu dokter dalam menyingkirkan diagnosis abses retropharyngeal. 5. Computerized tomography (CT scan): biasanya tampak kumpulan cairan hypodense di apex tonsil yang terinfeksi (the affected tonsil), dengan peripheral rim enhancement. 6. Ultrasound, contohnya: intraoral ultrasonography.

KOMPLIKASI Komplikasi yang mungkin terjadi ialah2: 1. Abses pecah spontan, mengakibatkan perdarahanm aspirasi paru, atau piema. 2. Penjalaran infeksi dan abses ke daerah parafaring, sehingga terjadi abses parafaring. Kemudian dapat terjadi penjalaran ke mediastinum menimbulkan mediastinitis. 3. Bila terjadi penjalaran ke daerah intracranial, dapat mengakibatkan thrombus sinus kavernosus, meningitis, dan abses otak. Sejumlah komplikasi klinis lainnya dapat terjadi jika diagnosis PTA diabaikan. Beratnya komplikasi tergantung dari kecepatan progression penyakit. Untuk itulah diperlukan penanganan dan intervensi sejak dini. DIAGNOSIS BANDING Infiltrat peritonsil, tumor, abses retrofaring, abses parafaring, aneurisma arteri karotis interna, infeksi mastoid, mononucleosis, infeksi kelenjar liur, infeksi gigi, dan adenitis tonsil2,8,9. TERAPI Pada stadium infiltrasi, diberikan antibiotika dosis tinggi dan obat simtomatik. Juga perlu kumur-kumur dengan air

hangat dan kompres dingin pada leher. Antibiotik yang diberikan ialah penisilin 600.000-1.200.000 unit atau ampisilin/amoksisilin 3-4 x 250-500 mg atau sefalosporin 3-4 x 250-500 mg, metronidazol 3-4 x 250-500 mg2. Bila telah terbentuk abses, dilakukan pungsi pada daerah abses, kemudian diinsisi untuk mengeluarkan nanah. Tempat insisi ialah di daerah yang paling menonjol dan lunak, atau pada pertengahan garis yang menghubungkan dasar uvula dengan geraham atas terakhir. Intraoral incision dan drainase dilakukan dengan mengiris mukosa overlying abses, biasanya diletakkan di lipatan

supratonsillar. Drainase atau aspirate yang sukses menyebabkan perbaikan segera gejala-gejala pasien. Bila terdapat trismus, maka untuk mengatasi nyeri, diberikan analgesia lokal di ganglion sfenopalatum. Kemudian pasien dinjurkan untuk operasi tonsilektomi a chaud. Bila tonsilektomi dilakukan 3-4 hari setelah drainase abses disebut tonsilektomi a tiede, dan bila tonsilektomi 4-6 minggu sesudah drainase abses disebut tonsilektomi a froid. Pada umumnya tonsilektomi dilakukan sesudah infeksi tenang, yaitu 2-3 minggu sesudah drainase abses2. Tonsilektomi merupakan indikasi absolut pada orang yang menderita abses peritonsilaris berulang atau abses yang meluas pada ruang jaringan sekitarnya. Abses peritonsil mempunyai kecenderungan besar untuk kambuh. Sampai saat ini belum ada kesepakatan kapan tonsilektomi dilakukan pada abses peritonsil. Sebagian penulis menganjurkan tonsilektomi 68 minggu kemudian mengingat kemungkinan terjadi perdarahan atau sepsis, sedangkan sebagian lagi menganjurkan tonsilektomi segera10.

Gambar 3. tonsilektomi Penggunaan steroids masih kontroversial. Penelitian terbaru yang dilakukan Ozbek mengungkapkan bahwa penambahan dosis tunggal intravenous dexamethasone pada antibiotik parenteral telah terbukti secara signifikan

mengurangi waktu opname di rumah sakit (hours hospitalized), nyeri tenggorokan (throat pain), demam, dan trismus dibandingkan dengan kelompok yang hanya diberi antibiotik parenteral. PROGNOSIS Abses peritonsoler hampir selalu berulang bila tidak diikuti dengan tonsilektomi., maka difunda sampai 6 minggu berikutnya. Pada saat tersebut peradangan telah mereda, biasanya terdapat jeringan fibrosa dan granulasi pada saat oprasi. DAFTAR PUSTAKA 1. Adams, G.L. 1997. Penyakit-Penyakit Nasofaring Dan Orofaring. Dalam: Boies, Buku Ajar Penyakit THT, hal.333. EGC, Jakarta. 2. Fachruddin, darnila. 2006. Abses Leher Dalam. Dalam: Buku Ajar Ilmu Kesehatan, Telinga-Hidung-Tenggorokan, hal. 185. Balai Penerbit FKUI, Jakarta. 3. Soepardi,E.A,

Iskandar, H.N, Abses Peritonsiler, Buku Ajar Ilmu Kesehatan Telinga, Hidung dan Tenggorokan, Jakarta: FKUl, 2000; 185-89. 4. Mehta, Ninfa. MD. Peritonsillar Abscess. Available from. www.emedicine.com. Accessed at Juli 2007. 5. Adrianto, Petrus. 1986. Penyakit Telinga, Hidung dan Tenggorokan, 296, 30809. EGC, Jakarta. 6. Bailey, Byron J, MD. Tonsillitis, Tonsillectomy, and Adenoidectomy. In : Head and Neck Surgey-Otolaryngology 2nd Edition. Lippincott_Raven Publisher. Philadelphia. P :1224, 1233-34. 7. Anurogo, Dito. 2008. Tips Praktis Mengenali Abses Peritonsil. Accessed: http://www.kabarindonesia.com/berita.php?pil=3&dn=20080125161248. 8. Preston, M. 2008. Peritonsillar Abscess (Quinsy). accessed: http://www.patient.co.uk/showdoc/40000961/. 9. STEYER, T. E. 2002. Peritonsillar Abscess: Diagnosis and Treatment. accessed: http://www.aafp.org/afp/20020101/93.html.

10. Hatmansjah. Tonsilektomi. Cermin Dunia Kedokteran Vol. 89, 1993. Fakultas Kedokteran Universitas Indonesia, hal : 19-21.

January 1, 2002 Table of Contents

This is a corrected version of the article that appeared in print.

Peritonsillar Abscess: Diagnosis and Treatment

TERRENCE E. STEYER, M.D., University of Michigan Medical School, Ann Arbor, Michigan.

Am Fam Physician.2002Jan1;65(1):93-97.

Peritonsillar abscess, the most common deep infection of the head and neck that occurs in adults, is typically formed by a combination of aerobic and anaerobic

bacteria. The presenting symptoms include fever, throat pain, and trismus. Ultrasonography and computed tomographic scanning are useful in confirming a diagnosis. Needle aspiration remains the gold standard for diagnosis and treatment of peritonsillar abscess. After performing aspiration, appropriate antibiotic therapy (including penicillin, clindamycin, cephalosporins, or metronidazole) must be initiated. In advanced cases, incision and drainage or immediate tonsillectomy may be required.

Peritonsillar abscess is the most common deep infection of the head and neck that occurs in adults. This infection begins as a superficial infection and progresses into tonsillar cellulitis. A peritonsillar abscess forms at the most advanced stage. Early diagnosis of the abscess allows appropriate treatment to begin before the abscess spreads into the surrounding anatomic structures. A family physician who has appropriate training can diagnose and treat the majority of patients with peritonsillar abscess.

Epidemiology

Peritonsillar abscess is most common in persons 20 to 40 years of age. Young children are seldom affected unless they are immuno-compromised, but the infection can cause significant airway obstruction in children.1,2 This infection affects males and females equally. Evidence shows that chronic tonsillitis or multiple trials of oral antibiotics for acute tonsillitis may predispose persons to the development of a peritonsillar abscess.3

Anatomy

The normal anatomy of the palatine tonsils and their surrounding tissues is depicted in Figure 1. The two tonsillar pillars define the palatine tonsils anteriorly and posteriorly. The glossopalatine and the pharyngopalatine muscles are the major muscles of the anterior and posterior pillars, respectively. The tonsil lays in the depression between the palatoglossal and the palatopharyngeal arches.4

FIGURE 1.

Normal anatomy of the palatine tonsils and their surrounding tissue.

During the embryonic stage, the tonsils arise from the second pharyngeal pouch as buds of endodermal cells.5 Shortly after birth, the tonsils grow irregularly and reach their ultimate size and shape, depending on the amount of lymphoid tissue present.

Each tonsil has an irregular number of ingrowths of the surface epithelium known as tonsillar crypts. The tonsils are surrounded by a capsule, a specialized portion of the intrapharyngeal aponeurosis that covers the medial portion of the tonsils and provides a path for blood vessels and nerves through its fibers.6

Peritonsillar abscesses form in the area between the palatine tonsil and its capsule. If the abscess progresses, it can involve the surrounding anatomy, including the masseter muscles and the pterygoid muscle. If severe, the infection can also penetrate the carotid sheath.

Etiology

The most common organisms associated with peritonsillar abscess are listed in Table 1. Streptococcus pyogenes (group A beta-hemolytic streptococcus) is the most common aerobic organism associated with peritonsillar abscess. The most common anaerobic organism is Fusobacterium. For most abscesses, a mixed profile of both aerobic and anaerobic organisms cause the infection.79 TABLE 1 Common Organisms Associated with Peritonsillar AbscessAerobic Anaerobic

Streptococcus pyogenes Fusobacterium

Staphylococcus aureus Peptostreptococcus

Haemophilus influenzae Prevotella

Neisseria species Bacteroides

Diagnosis

The most important information to obtain during the patient's history is the location of the pain in the throat, which suggests the location of the abscess. A thorough history should determine if the patient has a fever, has difficulty swallowing or has possibly ingested foreign objects. During the physical examination, trismus (inability or difficulty in opening the mouth) is often present because of inflammation of the pharyngomaxillary space and pterygoid muscle.1 A distinguishing feature on physical examination is the inferior medial displacement of the infected tonsil with a contralateral deviation of the uvula (Figure 2).3 In addition, many patients will have a thickened, muffled voice often described as having a hot potato quality. The most common findings from the history and physical examination are summarized in Table 2.

This illustration was removed because it didn't accurately portray the intended image. [corrected]

FIGURE 2.

Contralateral deviation of uvula with tonsillar edema. TABLE 2 Common Symptoms and Physical Examination Findings in Patients with Peritonsillar Abscess Symptoms Physical examination

Progressively worsening sore throat, often localized to one side Fever Dysphagia Otalgia Odynophagia Erythematous, swollen tonsil with contralateral uvular deviation Trismus Edema of palatine tonsils Purulent exudate on tonsils Drooling Muffled, hot potato voice Cervical lymphadenopathy

Table 3 outlines the differential diagnosis of peritonsillar abscess. Peritonsillar cellulitis is present when the area between the tonsil and its capsule is erythematous but lacks pus. The presence of mononucleosis can be determined by obtaining a complete blood count and a heterophile screen. During the physical examination, the physician should perform a thorough intraoral inspection to rule out an infection of the salivary glands, teeth, and mastoid bone, as well as neoplasms, cervical adenitis, and aneurysm of the internal carotid artery.

TABLE 3 Differential Diagnosis of Peritonsillar Abscess Peritonsillar cellulitis Cervical adenitis

Tonsillar abscess Dental infections

Mononucleosis Salivary gland infection

Foreign body aspiration Mastoid infection

Neoplasms (lymphoma, leukemia) Aneurysm of internal carotid artery

A thorough history and physical examination can often determine a diagnosis of peritonsillar abscess, but radiologic tests may be helpful in differentiating peritonsillar abscess from other diagnoses. Ultrasonography is the easiest and most useful tool. The ultrasound can be obtained transcutaneously by placing the transducer over the sub-mandibular gland and scanning the entire tonsillar area.

If there is a peritonsillar abscess, the abscess formation will be demonstrated as an echo-free cavity with an irregular, well-defined circumference.10 The ultrasound can also be performed intraorally by placing the patient in a sitting position. With the use of a tongue blade, the probe can be used to scan the tonsils for echo-free areas. The presence of trismus may limit the ability to use intraoral sonography.11,12

The use of computed tomographic (CT) scanning may also be helpful in identifying an abscess formation. The CT scan should be obtained with contrast to allow for optimal viewing of the abscess. An area of low attenuation on a contrast-enhanced CT scan is suggestive of abscess formation. Other indications of a peritonsillar abscess that are present on CT scanning include diffuse swelling of the soft tissues with loss of the fat planes and the presence of edema in the surrounding area.13,14

NEEDLE ASPIRATION

The gold standard for diagnosis of peritonsillar abscess remains the collection of pus from the abscess through needle aspiration. To obtain this sample, the area should be anesthetized with 0.5 percent benzalkonium (Cetacaine spray) followed by a gargle of 2 percent lidocaine (Xylocaine) with epinephrine. A no. 18-gauge spinal needle attached to a 10-mL syringe can be used to obtain material from the suspected abscess. Figure 3 illustrates this procedure being performed. The fluid obtained should be sent to the laboratory for gram stain and culture to determine the appropriate treatment regimen.

This illustration was removed because it didn't accurately portray the intended image.[corrected]

FIGURE 3.

Needle aspiration of peritonsillar abscess.

A needle aspiration of a peritonsillar abscess should only be performed by properly trained physicians. Complications of performing the aspiration can include aspiration of pus and blood, and hemorrhage. If the abscess is located in the distal part of the tonsil, puncture of the carotid artery can occur.

Treatment

The treatment of peritonsillar abscess requires both the selection of appropriate antibiotics and the best procedure to remove the abscessed material. Individualized treatment modalities will result in more successful outcomes.

The choice of antibiotics is highly dependent on both the gram stain and culture of the fluid obtained from the needle aspiration. Penicillin used to be the antibiotic of choice for the treatment of peritonsillar abscess, but in recent years the emergence of beta-lactamase-producing organisms has required a change in antibiotic choice.15 Results of studies16,17 suggest that 500 mg of clindamycin administered twice daily or a second- or third-generation oral cephalosporin be used instead of penicillin.

Another study1 recommends using penicillin as the first-line agent, and, if there is no response within the first 24 hours, adding 500 mg of metronidazole administered twice daily to the regimen. All specimens should be examined by culture for antibiotic sensitivity to ensure appropriate antibiotic coverage.

Three main surgical procedures are available for the treatment of peritonsillar abscess: needle aspiration, incision and drainage, and immediate tonsillectomy. Three recent studies have compared needle aspiration with incision and drainage for the treatment of peritonsillar abscess.1618

In one study,16 52 consecutive patients who had a positive needle aspiration of a peritonsillar abscess were randomized into two groups comparing needle aspiration alone with incision and drainage.8 There were no significant differences between the two groups in duration of symptoms or initial treatment failure. The results indicated that no further surgical management for peritonsillar abscess was required following the initial needle aspiration. Another study17 conducted in 1991 reported similar results.

A retrospective study18 of 160 patients compared patients who received needle aspiration alone with patients who had undergone incision and drainage. In this

study, only eight patients (0.5 percent) required incision and drainage after multiple failed needle aspirations. The authors concluded that needle aspiration alone was an appropriate treatment regimen, but a higher rate of recurrence occurred that could ultimately require incision and drainage.

Controversy remains over the necessity of incision and drainage versus needle aspiration alone. However, most otolaryngologists consider incision and drainage to be the gold standard for treatment. An otolaryngologist should usually be consulted to perform this procedure unless the treating physician has the appropriate experience and training. A review of the incision and drainage technique for peritonsillar abscess is beyond the scope of this article.

Most experts agree that immediate tonsillectomy is not required for treatment of peritonsillar abscess. Tonsillectomy should be performed three to six months after the abscess in patients who have recurrent tonsillitis or peritonsillar abscess. If the family physician is inexperienced in treating peritonsillar abscess, an otolaryngologist should be consulted at the time of the diagnosis to determine the appropriate surgical treatment.

The Author

TERRENCE E. STEYER, M.D., is currently assistant professor in the Department of Family Medicine at the Medical University of South Carolina, Charleston. Dr. Steyer received his medical degree from Case Western Reserve University School of Medicine, Cleveland, Ohio. He completed a family medicine residency at Wake Forest University Baptist Medical Center, Winston-Salem, N.C. Dr. Steyer wrote this article while serving as a Robert Wood Johnson Clinical Scholar and a lecturer in the Department of Family Medicine at the University of Michigan Medical School, Ann Arbor.

Address correspondence to Terrence E. Steyer, M.D., Department of Family Medicine, Medical University of South Carolina, 295 Calhoun St., P.O. Box 250192, Charleston, SC 29425-0192 (e-mail: steyerte@musc.edu). Reprints are not available from the author.

The author wishes to thank Barbara Apgar, M.D., M.S., and Tara Hogue for assistance in the preparation of the manuscript and Clark Malcolm for editorial assistance.

The author indicates that he does not have any conflicts of interest. Sources of funding: none reported.

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Members of various medical faculties develop articles for Practical Therapeutics. This article is one in a series coordinated by the Department of Family Medicine at the University of Michigan Medical School, Ann Arbor. Guest editor of the series is Barbara S. Apgar, M.D., M.S., who is also an associate editor of AFP.

Copyright 2002 by the American Academy of Family Physicians.