Case Conference: Peritonsillar Abscess

by Bob Stuntz in ,


Case Conference: Peritonsillar Abscess

    Peritonsillar abscess is the most common deep space infection in the neck.  Usually seen in patients in their 20’s and 30’s, it is a disease of young, healthy people.  Signs and symptoms include:

  • Trismus
  • Muffled, “hot potato” voice
  • Fever
  • Odynophagia, dysphagia, drooling
  • Uvular deviation away from abscess
  • Asymmetric tonsillar swelling

    Bedside ultrasound can both help diagnose PTA as well as guide needle aspiration.  There is no difference in outcomes between patients who undergo I/D and needle aspiration, so just use the needle (18g preferably).  

    Avoid the carotid artery at all costs.  The blind technique calls for directing the needle medially and not advancing more than one centimeter deep.  Multiple techniques have been described to guard the needle from going deeper (cutting the needle cap about a centimeter down from the tip for instance).  I think the easiest way to keep the needle tip away from big red: ultrasound guidance!  You always no where your needle tip is, and there is no need to MacGyver your needle.  

    Steroids may be of benefit in terms of improved symptoms and decreased hospital stay, but a risk-benefit analysis should be performed and they are not globally indicated.  Disposition depends on many factors, and patients should be treated with antibiotics as described in the podcast.  

References

  1. Powell, J. & Wilson, J.A.  An evidence-based review of peritonsillar abscess. Clin. Otolaryngology.  2012, 37, 136-145. 
  2. Falcon-Chevere, JL et. al. Critical ENT Skills and Procedures in the Emergency Department. Emerg Med Clin N Am 31 (2013) 29–58
  3. Costantino, TG et. al.  Randomized Trial Comparing Intraoral Ultrasound to Landmark-based Needle Aspiration in Patients with Suspected Peritonsillar Abscess. Academic Emergency Medicine 2012; 19:626–631
  4. Lyon, M; Blaivas, M.  Intraoral ultrasound in the diagnosis and treatment of suspected peritonsillar abscess in the emergency department.  Academic Emergency Medicine.  2005 Jan;12(1):85-8.  
  5. Emergency Medicine: A Focused Review of the Core Curriculum.  AAEM.  p 202. 
  6. https://wiki.uiowa.edu/display/protocols/Peritonsillar+Abscess+Management
  7. http://www.ultrasoundpodcast.com/2012/01/episode-21-full-peritonsillar-abscess-podcast/
  8. http://academiclifeinem.blogspot.com/2012/04/trick-of-trade-peritonsillar-abscess.html 
  9. EMRAP July 2011: ENT potpourri by Rob Orman and Sam Shiley (45 min)

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