PERITONSILAR ABSES

A peritonsillar abscess (PTA) is a localized accumulation of pus in the peritonsillar tissues that
forms as a result of suppurative tonsillitis. The nidus of accumulation is located between the
capsule of the palatine tonsils and the constrictor muscles of the pharynx. The anterior and
posterior pillars, torus tubarius (superior), and pyriform sinus (inferior) form the boundaries of
this potential peritonsillar space. Because it is composed of loose connective tissue, severe
infection of this area may rapidly lead to formation of purulent material. Progressive
inflammation and suppuration may extend to directly involve the soft palate, the lateral wall of
the pharynx, and, occasionally, the base of the tongue.
History of the Procedure: Common sites of infection, PTAs have been described as early as
the 14th century; however, only since the advent of antibiotics in the 20th century has the
condition been described more extensively.
Problem: PTA usually is a complication of an acute tonsillitis. Inflammatory edema may lead
to significant difficulty in swallowing. Dehydration frequently occurs secondary to the patient's
avoidance of painful ingestion of food and liquids. Expansion of the abscess may lead to
extension of the inflammation into adjacent fascial compartments of the head and neck,
potentially leading to airway obstruction.
Frequency: The incidence of PTA in the United States is about 30 cases per 100,000 people
per year, representing about 45,000 new cases each year. No accurate data are available
internationally. Although tonsillitis is a disease of childhood, only one third of PTA cases are
found in this age group. The age of patients is variable, ranging from 1-76 years, with the
highest incidence in the group aged 15-35 years.
Etiology: Any of the microorganisms that cause acute or chronic tonsillitis may be the
causative organisms of a PTA. Most commonly, aerobic and anaerobic gram-positive
organisms are identified by culture. Cultures of affected patients reveal group A beta-hemolytic
streptococci as most prevalent. Next most commonly, staphylococci, pneumococci, and
Haemophilus organisms are found. Finally, other microorganisms that can be cultured include
lactobacilli, filamentous forms such as Actinomyces species, micrococci, Neisseria species,
diphtheroids, Bacteroides species, and nonsporulating bacteria. Some evidence indicates that
anaerobic bacteria frequently cause these infections.
Pathophysiology: The pathophysiology of PTA is unknown. The most widely accepted theory
is the progression of an episode of exudative tonsillitis first into peritonsillitis and then into
frank abscess formation. Extension of the inflammatory process may occur in both treated and
untreated populations. PTA also has been documented to arise de novo without any prior
history of recurrent or chronic tonsillitis. A PTA also can be the presentation of an Epstein-Barr
virus (ie, mononucleosis) infection.

Another theory proposes the origin of PTA in Weber glands. These minor salivary glands are
found in the peritonsillar space and are thought to help in clearing debris from the tonsils.
Should obstruction as a result of scarring from infection occur, tissue necrosis and abscess
formation result, leading to PTA.
Clinical:
History
Patients typically present with a history of acute pharyngitis accompanied by tonsillitis and
worsening unilateral pharyngeal discomfort. Patients also may experience malaise, fatigue, and
headaches. They often present with a fever and asymmetric throat fullness. Associated
odynophagia, dysphagia, and a hot potatosounding voice occur.
Many patients present with ipsilateral referred otalgia with swallowing. Trismus (ie, a
limitation in the ability to open the oral cavity) of varying severity is present in all cases,
reflecting lateral pharyngeal wall and pterygoid musculature inflammation. Because of
lymphadenopathy and cervical muscle inflammation, patients often experience neck pain and
even a limitation in neck mobility. Clinicians need to be alerted to the diagnosis of a PTA in
patients with persisting pharyngeal symptoms despite an adequate antibiotic regimen.
Physical examination
The presentation may vary from acute tonsillitis with unilateral pharyngeal asymmetry to
dehydration and sepsis. Most patients have severe pain. Examination of the oral cavity reveals
marked erythema, asymmetry of the soft palate, tonsillar exudation, and contralateral
displacement of the uvula.
A PTA ordinarily is unilateral and located at the superior pole of the affected tonsil, in the
supratonsillar fossa. At the level of the supratonsillar fold, the mucosa may appear pale and
even show a small pimple. Palpation of the soft palate often reveals an area of fluctuance.
Flexible nasopharyngoscopy and laryngoscopy are recommended in patients experiencing
airway distress. The laryngoscopy is key to rule out epiglottitis and supraglottitis, as well as
vocal cord pathology.
The degree of trismus depends on the extent of lateral pharyngeal space inflammation. If it is
very marked, one should be concerned with the possibility of a lateral pharyngeal space
cellulitis. The finding of tender ipsilateral cervical lymphadenopathy involving single or
multiple nodes is not uncommon. The affected lymph nodes may be quite firm. In presentations
with significant nodal inflammation, the patient may experience torticollis and limitation of
neck mobility. A more detailed evaluation is essential if suspicion of an accompanying cervical
abscess exists.

INDICATION

WORK UP

Indications for considering the diagnosis of a PTA include the following:

Lab Studies:

Unilateral swelling of the peritonsillar area

CBC count, electrolyte level, blood culture: Patients presenting with PTAs often are
septic in appearance and may demonstrate varying degrees of dehydration due to
abstention from oral intake. Assessment of these 2 entities should involve the
collection of blood for a complete blood count, electrolyte level measurement, and
blood cultures.

Monospot test

Unilateral swelling of the soft palate, with anterior displacement of the ipsilateral
tonsil
Nonresolution of acute tonsillitis, with persistent unilateral tonsillar enlargement

In cases of PTA, when incision and drainage (I&D) is performed, it leads to immediate
improvement of the patient's symptoms. Needle aspiration may be used both as a diagnostic
and as a therapeutic modality because it allows the accurate localization of the abscess cavity.
The fluid aspirated may be sent for culture, and, in some cases, an I&D may not be necessary.
If patients continue to report recurring and/or chronic sore throats following proper I&D, a
tonsillectomy may be indicated.
RELEVANT ANATOMY AND CI
Relevant Anatomy: The palatine tonsils are paired lymphoid organs found between the
palatoglossal and palatopharyngeal folds of the oropharynx. They are surrounded by a thin
capsule that separates the tonsil from the superior and middle constrictor muscles.
The anterior and posterior pillars form the front and back limits of the peritonsillar space.
Superiorly, this potential space is related to the torus tubarius, while inferiorly it is bounded by
the pyriform sinus. Composed solely of loose connective tissue, a severe infection may rapidly
result in pus formation. The inflammation and suppurative process may extend to involve the
soft palate, the lateral wall of the pharynx, and, occasionally, the base of the tongue.
The tonsillar fossa has a rich network of lymphatic vessels leading to the parapharyngeal space
and the upper cervical lymph nodes, which explains the pattern of adenopathy observed
clinically. Ipsilateral upper cervical lymphadenopathy is the result of the spread of infection to
the regional lymphatics. Occasionally, the severity of the suppurative process may lead to a
cervical abscess, especially in very fulminant or rapidly progressive cases.
Contraindications: Intraoral drainage has a high rate of success and a low rate of recurrence
and morbidity. Normally, unless the patient presents with recurrent tonsillitis or recurrent PTA,
tonsillectomy is not indicated. However, in situations in which the abscess is located in an area
difficult to access, a tonsillectomy may be the only way to drain the abscess.

In patients presenting with tonsillitis and bilateral cervical

lymphadenopathy, a Monospot test (heterophile antibodies) should be
considered.

If the test results are positive, the patient requires careful evaluation of
hepatosplenomegaly. Liver function tests should be considered in
patients with hepatomegaly.

Throat culture: To facilitate the identification of infectious organisms, a throat swab

and culture are to be considered. The results may assist in selection of the most
appropriate antibiotic once the organism is identified, limiting the risk of antibiotic
resistance.

Imaging Studies:

Imaging may be particularly useful in cases where an attempt at I&D has failed or
where worsening edema in a treated peritonsillar cellulitis is noted. In certain cases,
the abscess may be within the tonsil itself and/or partially hidden (ie, inferior or
posterior) by the tonsil.

Plain radiographs

Lateral soft tissue views of the nasopharynx and oropharynx may help
the clinician rule out a retropharyngeal abscess.

In the anteroposterior view, the films reveal distortion of soft tissues but
are not useful in localizing an abscess.

Computerized tomography

In selected clinical settings and in very young patients, radiological

evaluation may be performed with a CT scan of the oral cavity and neck
using intravenous contrast enhancement.

Common findings are the presence of a hypodense fluid collection in the

apex of the affected tonsil, with peripheral rim enhancement.

Other findings may include an asymmetric enlargement of the tonsils

and surrounding fossa.

The aspiration site is anesthetized using lidocaine with epinephrine and a

large-bore (#16- to 18-gauge) needle is mounted on a 10-cc syringe.

The needle is passed through the anesthetized mucosa where aspiration

of the site is performed.

Aspiration of purulent material is diagnostic, and the material may be

sent for culture.

TREATMENT
Medical therapy:

Further delineation of cervical adenopathy is facilitated, as is the

identification of a possible intranodal fluid collection, which indicates a
cervical abscess and helps in the planning of surgical management.

Intraoral ultrasonography recently has been proposed as an imaging

modality. It is a simple, well-tolerated, noninvasive technique that can
help the physician make the distinction between cellulitis and the
presence of an abscess.

Needle aspiration

This also allows the option of a more directed aspiration of the tonsillar
fossa before definitive surgical drainage is attempted. A recent study has
shown that this approach is also clinically useful in the evaluation of
patients presenting in the emergency department.

Diagnostic Procedures:

Ultrasound

A needle aspiration of the abscess site may be performed just prior to

attempting the drainage procedure. It allows identification of the
location of the abscess in the peritonsillar space.

Patients with dehydration require intravenous fluid administration until the

inflammation resolves and they are able to resume an adequate oral fluid intake.
Antipyretics and analgesics are used to alleviate fever and discomfort.
Oral and parenteral analgesics are an integral part of the management and allow the
patient to resume oral intake. Often, the pain relief is so significant from I&D as to
allow the patient to resume oral intake with nonnarcotic analgesics.
Antibiotic therapy should begin after cultures are obtained from the abscess. The
use of high-dose intravenous penicillin remains a good choice for the empiric
treatment of PTA.
Alternatively, due to the polymicrobial nature of cultured pus, agents that treat
copathogens and resist beta-lactamases also have been recommended as a first
choice.
Cephalexin or other cephalosporins (with or without metronidazole) are likely the
best initial option. Alternatives include (1) cefuroxime or cefpodoxime (with or
without metronidazole), (2) clindamycin, (3) trovafloxacin, or (4)
amoxicillin/clavulanate (if mononucleosis has been ruled out). The patient may be
prescribed oral antibiotics once oral intake is tolerated; length of treatment should
be 7-10 days.
The use of steroids has been controversial. In a recent study by Ozbek, the addition
of a single dose of intravenous dexamethasone to parenteral antibiotics has been
found to significantly lessen the variables of hours hospitalized, throat pain, fever,
and trismus compared with a group of patients who were only treated with
parenteral antibiotics. In addition, the use of steroids in patients presenting with
signs and symptoms of mononucleosis has not led to the formation of a peritonsillar
abscess.

Surgical therapy: The management of patients suspected of a PTA should include a referral to
an otolaryngologist or a surgeon with experience in the management of this entity. Early
referral should be considered if the diagnosis is unclear and is indicated in patients presenting
with airway obstruction.

Preoperative details:

Discussing the pathophysiology and indications for surgery with the patient is
essential.
Consent should be obtained from the patient or surrogate only after carefully
describing potential complications.
In cases in which airway access may be compromised, an emergent consultation
with the anesthesiologist is obtained, and the potential of airway obstruction is
discussed.
If necessary, the anesthesiologist may perform an intubation using a flexible
bronchoscope with the patient in the semisupine position.
A significant potential for airway obstruction exists if the patient's airway access is
limited by significant trismus or by edema of the oropharyngeal structures.

Intraoperative details: Ongoing controversy exists regarding needle aspiration versus I&D as
definitive therapeutic modalities. In cooperative patients, procedures may be performed in an
examination chair. The supratonsillar fold is anesthetized by either mucosalization or injection
of a local anesthetic with epinephrine to reduce bleeding. If injection of a local anesthetic is
performed, care should be taken to superficially infiltrate the overlying mucosa and
surrounding soft palate.
Needle aspiration

Needle aspiration can be carried out in children as young as 7 years, especially if

conscious sedation is used.
Needle aspiration may be used both as a diagnostic and as a therapeutic modality
because it allows the accurate localization of the abscess cavity.
The fluid aspirated may be sent for culture and, in some cases, may not need to be
followed by an I&D.

Incision and drainage

Intraoral incision and drainage is performed by incising the mucosa overlying the
abscess, usually located in the supratonsillar fold.

Once the abscess is localized, blunt dissection is carried out to break loculations.
The opening is left open to drain, and the patient is asked to gargle with a sodium
chloride solution, allowing the accumulated material to exit the abscess cavity.
A successful aspirate or drainage leads to immediate improvement of the patient's
symptoms.

Other concerns

In very young or uncooperative patients or when the abscess is located in an

unusual location, the procedure is best performed under general anesthesia.
Immediate tonsillectomy as part of the management of a PTA also has been a
subject of controversy. Many studies have shown the safety of a tonsillectomy in
the setting of an acute abscess. Others have shown that immediate or delayed
tonsillectomy may not be necessary because of the high rate of success and low
rates of recurrence and morbidity associated with intraoral drainage.
In situations in which the abscess is located in an area difficult to access, a
tonsillectomy may be the only way to drain the abscess.

Postoperative details:

Due to the rapid improvement in pain, most patients may be discharged

immediately following the procedure if they are able to tolerate oral intake of fluids
and bleeding is not apparent.
Some patients may require admission in the hospital setting for 24-48 hours or until
oral intake is properly reestablished and pain is well controlled.
Intravenous hydration is important because most patients present with significant
fluid deficits.
Continued use of antibiotics in the postoperative period also is important. When the
patient is able to take sufficient fluids by mouth, antibiotics may be administered
orally for a total length of treatment of 7-10 days.
Oral analgesics also are important due to the level of discomfort from the ongoing
inflammation.

Follow-up care: Patients are seen routinely in follow-up in the office setting. Elements to
consider at that time are reduction of the amount of pain, defervescence, and ability to
comfortably resume oral intake.
During the examination, carefully inspecting the drainage site and ruling out re-accumulation
of pus is important; check for improvement in tonsillar appearance, inflammation, and the

resolution of cervical lymphadenopathy. In general, unless the patient presents with a history of
recurring tonsillitis or recurrent PTA, tonsillectomy is not indicated.
For excellent patient education resources, visit eMedicine's Ear, Nose, and Throat Center. Also,
see eMedicine's patient education articles Peritonsillar Abscess, Tonsillitis, and Antibiotics.

COMPLICATION

A number of clinical complications may occur if the diagnosis of a PTA is missed or

delayed. The severity of the complications depends on the rapidity of progression of
the illness as well as the characteristics of the affected fascial spaces. Early
management and intervention are important.
The fascial spaces of the neck are interconnected. Once inflammation exceeds the
limits of the peritonsillar space, involvement of the masticator space (with
increasing degrees of trismus) occurs. Extension may progress to the submandibular
and sublingual spaces within the floor of the mouth (Ludwig angina). At this point,
emergent airway control through intubation or tracheotomy is indicated to obviate
obstruction from swelling of the base of the tongue. In severe cases, death may
occur.
In patients treated with I&D, evaluating the patency of the opening is important.
Premature closure before the cavity has become obliterated is possible, leading to
re-accumulation of pus. This may warrant a second I&D procedure or a
tonsillectomy.
Limiting the drainage incision to the mucosa of the soft palate and using blunt
dissection within the cavity are important to avoid serious bleeding. The terminal
branches of the external carotid artery lie on the posterior aspect of the tonsillar
fossa and can be injured easily, particularly in children, in whom they are relatively
superficial.
Bleeding is a potential complication if branches of the external carotid artery are
injured or if the external carotid artery itself is injured. The bleeding may occur
intraoperatively or in the early postoperative period.
Intraoperative hemorrhage is an emergency and results from direct injury to
terminal branches of the external carotid artery or the external carotid artery itself.
Once the patient is stabilized hemodynamically, the tonsillar fossa is reevaluated.
The ipsilateral neck also should be prepared and draped in a sterile fashion for
access to the proximal external carotid artery. If the hemorrhage is controlled
intraorally, the patient's continued stabilization is pursued.
If the bleeding appears to be too brisk, and it is not controlled by careful intraoral
source identification, an ipsilateral cervicotomy is performed.

The sternocleidomastoid muscle is retracted laterally, and the carotid

sheath contents are identified. The internal jugular vein; the vagus nerve;
and the common, external, and internal carotid arteries are identified.
o A vascular loop is applied around the external carotid artery to assess
temporization of bleeding.
o The external carotid artery is dissected superiorly, with careful attention
to preservation of the external laryngeal, the ansa hypoglossi, and the
hypoglossal nerves.
o These severe life-threatening bleeds may require ligation of the external
carotid artery.
The general approach to postoperative hemorrhage similarly is directed to the
identification of the source of bleeding. The patient is brought to the operating
room, and the same procedure as described above is followed.

OUTCOME AND PROGNOSIS

Most patients treated with antibiotics and adequate drainage of their abscess cavity recover
within a few days. A small number present with another abscess later, requiring tonsillectomy.
If patients continue to report recurring and/or chronic sore throats following proper I&D, a
tonsillectomy may be indicated.
FUTURE AND CONTROVERSIES
Ongoing controversy exists regarding needle aspiration versus I&D as definitive therapeutic
modalities.
Immediate tonsillectomy as part of the management of a PTA also has been a subject of
controversy. Many studies have demonstrated the safety of a tonsillectomy in the setting of an
acute abscess. Others have shown that immediate or delayed tonsillectomy may not be
necessary because of the high rate of success and low rates of recurrence and morbidity
associated with intraoral drainage. In situations in which the abscess is located in an area
difficult to access, a tonsillectomy may be the only way to drain the abscess.