Peritonsillar Abscess Peritonsillar Abscess Algorithm

1. Spray the superior pole with topical anesthesia. Inject local anesthesia with epinephrine. Aspirate with 10 or 20 cc syringe and 18 or 20 gauge needle. 2. Organisms 10-15 are penicillin resistant Aero!es" Streptococcus, M. Catarrhalis H. influenzai, Staphylococcus Anaero!es" Bacteroides, Peptocci, Fusobacteria Peptostreptococci Anti!iotics #en $.%. 500 mg #.O. &id and 'lagyl 500 mg #.O. & 8 hrs. (!oth )or *-10 days+ or ,e)tin 500 mg #.O. !id i) #,- Allergic ..../0rythromycin 500 mg #.O. &id ,lindamycin 100 mg I$ drip2 )ollowed !y clindamycin 300 mg p.o. & 1 h is an alternati4e to the a!o4e and is a second line drug i) the a!o4e )ails.

Overview of Peritonsillar Abscess -o one really 5nows why a tonsillar a!scess de4elops. 6he !est theory I 5now is the )ollowing" there is a small gland in the so)t palate mucosa near the superior pole o) the tonsil called 7e!er8s gland. 6his occasionally !ecomes in)ected and when it does spreads into the peritonsillar space. 7hen this occurs a peritonsillar in)ection de4elops. #eritonsillar a!scess presents as would any !ad !acterial pharyngitis. 9ltimately2 the patient !ecomes increasingly ill. :i))iculty swallowing and e4en pain while spea5ing is common as the a!scess progresses. 6he pain is greater on the in)ected side. On physical e;amination it may loo5 li5e tonsillitis2 !ut on care)ul e;amination2 one will see that the u4ula is edematous2 the so)t palate and superior pole o) the tonsil are swollen and the tonsil is protruding into the pharyn;. 6he u4ula in the late stages2 de4iates away )rom the a!scess. Once the diagnosis is suspected2 treatment should !e instituted. <i4en the 1015 incidence o) penicillin resistent organisms2 one is o!liged to treat with more than a )irst generation penicillin. =y own opinion is to treat with penicillin and )lagyl or with clindamycin. =ost Otolaryngologists would )eel that all peritonsillar a!scesses should !e needle aspirated or incised and drained as a minimum. A num!er o) primary care physicians who see these in an earlier state might not agree. I) the tonsil is not particularly swollen and protu!erant2 !ut the diagnosis is suspect2 anti!iotic treatment is appropriate. Once an a!scess )orms2 anti!iotics alone will not cure the illness and some )orm o) drainage is re&uired. 6he easiest is needle aspiration. 6his is per)ormed !y anestheti>ing the superior pole o) the tonsil or the !ottom o) the so)t palate2 just a!o4e the tonsil. Spray )irst with a topical anesthetic such as" ,etacaine2 then ma5e a 1cc mucosal injection o) lidocaine and adrenaline. An 18 or 20 gauge needle2 pre)era!ly on a 20cc syringe is then inserted near the superior tonsillar pole and the a!scess contents aspirated. 7hen an a!scess e;ists2 it is not uncommon to aspirate 530 cc8s o) pus. 6he aspirate should !e sent )or culture and sensiti4ity. =any o) these patients are already alimenting poorly and it is our current practice to insert an intra4enous line2 administer 1-2 liters o) ?actated @ingers and as long as one has I$ access to administer the )irst dosage o) anti!iotics intra4enously. Assuming that the a!scess is not ad4anced2 assuming the patient is ha4ing no di))iculty with respiration and assuming the patient is swallowing su))iciently well to ta5e their medicine2 they can !e sent home. I) pus reaccumlates it can

!e reaspirated once or twice. 0-6 re)erral can !e made )or incision and drainageA howe4er this com!ined with the already e;isting discom)ort2 creates su))icient dysphagia and discom)ort that the patient o)ten re&uires hospitali>ation. <i4en concerns a!out recurrent peritonsillar a!scesses and gi4en that per)orming a tonsillectomy in the acute phase is easy and sa)e2 it is our current recommendation that i) the patient is sic5 enough to !e admitted they should !e !rought to the operating room and !oth tonsils resected. I) #6A is success)ully managed as an outpatient2 the literature reports a 5-15 recurrence rate. =ost recommend a prophylactic tonsillectomy. ,ertainly2 i) the peritonsillar a!scess !ecomes recurrent2 a tonsillectomy is indicated