PTA Case Conference

by Bob Stuntz in

Peritonsillar Abscess

About a month ago, I posted a video with the following history and questions.  Let’s take a look at the answers: 

A 23 year old male presents to the ED with 4 days of sore throat, getting much worse over the last 24 hours.  You note that he has a muffled sounding voice.  On exam, he has trismus, uvular deviation, L sided tonsillar asymmetry, and could seriously use a breath mint.  Your attending decides to perform an intraoral ultrasound to evaluate the patient, and you see the above image.  

1. What do you see?

As correctly pointed out by a few, what you were looking at was a peritonsillar abscess, noted as the anechoic circular area adjacent to the tonsillar tissue.  This is the most common deep space infection of the head and neck.  

2.  What is the next step in management?

First, you want to make your patient comfortable.  Start with some pain medicine.  Steroids have been shown in some studies to potentially decrease hospitalization time,  and perhaps help with symptom relief, but there is question as to the risk-benefit profile.  Use your clinical discretion.  Perform intramural US to confirm the presence of a PTA and distinguish from cellulitis.  Once comfortable, you may proceed with needle aspiration (no significant evidence that aspiration or ID are different in terms of outcomes).  I prefer ultrasound guidance.  More on that in the podcast.  

3.  Should you start antibiotics or not?

Antibiotics are indicated, with Penicillin and Flagyl being 98-99% effective in the below referenced review.  Nontoxic patient can be treated as an outpatient, while those who fail aspiration or I/D or are toxic may require surgical consultation.  

Want more in depth info?  Check out the podcast!