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Peritonsillar Abscess, Pediatric

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Peritonsillar Abscess, Pediatric

Basics

Description

Epidemiology

Infectious complication of tonsillitis or pharyngitis resulting in an accumulation of purulence in the tonsillar fossa. Also referred to as "quinsy. "

Abscess formation can often be prevented if appropriate antimicrobial therapy is initiated while the infection is still at the cellulitis stage.

- Cervical adenopathy - Drooling - Torticollis

Treating an abscess without surgical drainage is inadequate and can have airway-threatening implications.

  • Most common deep space infection of head and neck
  • Seen most commonly in adolescents but occasionally in younger children

Risk Factors

  • Tonsillitis
  • Pharyngitis

General Prevention

Pathophysiology

  • Infectious tonsillopharyngitis progresses from cellulitis to abscess.
  • The infection starts in the intratonsillar fossa, which is situated between the upper pole and the body of the tonsil and eventually extends around the tonsil.
  • The abscess is a suppuration outside the tonsillar capsule, in proximity to the upper pole of the tonsil, involving the soft palate.
  • Purulence usually collects within one tonsillar fossa, but it may be bilateral.
  • The pterygoid musculature may become irritated by pus and inflammation, which leads to the clinical finding of trismus.
  • Tonsillar and peritonsillar edema may lead to compromise of the upper airway.

Etiology

  • Most of these true abscesses are polymicrobial.
  • Group A Ž ²-hemolytic streptococci (GABHS)
  • α-Hemolytic streptococci
  • Staphylococcus aureus: Prevalence of methicillin-resistant S. aureus continues to increase.
  • Anaerobic bacteria play an important role:PrevotellaPorphyromonasFusobacteriumPeptostreptococcus
  • Possible synergy between anaerobes and GABHS
  • Gram negatives such as Haemophilus influenzae and, more rarely, Pseudomonas species may be isolated.
  • Prevotella
  • Porphyromonas
  • Fusobacterium
  • Peptostreptococcus

Commonly Associated Conditions

  • Tonsillitis or pharyngitis usually precedes its development.
  • Peritonsillar cellulitis is often associated with infectious mononucleosis.

Diagnosis

History

  • Fever and sore throatMost common initial complaints
  • Trouble swallowing, pain with opening the mouth (trismus), muffled ( "hot potato " ) voiceClassic presenting symptoms
  • Unilateral neck or ear painOther common presenting symptoms
  • Most common initial complaints
  • Classic presenting symptoms
  • Other common presenting symptoms

Physical Exam

  • Unilateral peritonsillar fullness or bulging of the posterior, superior, soft palateDiagnostic finding
  • Uvular deviationClassic finding, although it may be absent in the more rare bilateral peritonsillar abscess
  • Palpable fluctuance of palatal swellingCalls for urgent aspiration
  • Erythematous, edematous pharynx, with enlarged and exudative tonsilsCoexisting tonsillopharyngitis is common.
  • Cervical adenopathyCommon
  • DroolingOften present
  • TorticollisSometimes seen
  • Diagnostic finding
  • Classic finding, although it may be absent in the more rare bilateral peritonsillar abscess
  • Calls for urgent aspiration
  • Coexisting tonsillopharyngitis is common.
  • Common
  • Often present
  • Sometimes seen

Diagnostic Tests & Interpretation

  • WBC countNot a mandatory part of the workupUsually elevated with prominent left shift
  • Rapid streptococcal throat antigen studiesHelpful to diagnose GABHS infection
  • Gram stain and culture of aspirate specimenConfirms causative microorganism
  • Monospot/EBV antibody titersNot a mandatory part of the workupInfectious mononucleosis is both in the differential diagnosis and may coexist in some cases of peritonsillar abscess.
  • Not a mandatory part of the workup
  • Usually elevated with prominent left shift
  • Helpful to diagnose GABHS infection
  • Confirms causative microorganism
  • Not a mandatory part of the workup
  • Infectious mononucleosis is both in the differential diagnosis and may coexist in some cases of peritonsillar abscess.
  • Radiographic studies are rarely necessary, as this is clinical diagnosis.
  • Intraoral ultrasound or CT (with contrast):Sometimes useful if clinical distinction of peritonsillar cellulitis from peritonsillar abscess is difficultCT scan is most useful if patient cannot open mouth secondary to trismus.CT scan is also important if deep neck extension is suspected.
  • MRIMRI may be more precise than CT in detecting multiple space involvement and, of course, is devoid of radiation exposure.Pediatric use is limited by need for longer acquisition time and greater need for patient cooperation.In younger children, the need for sedation for MRI introduces additional logistical challenges and potential airway risks.
  • Sometimes useful if clinical distinction of peritonsillar cellulitis from peritonsillar abscess is difficult
  • CT scan is most useful if patient cannot open mouth secondary to trismus.
  • CT scan is also important if deep neck extension is suspected.
  • MRI may be more precise than CT in detecting multiple space involvement and, of course, is devoid of radiation exposure.
  • Pediatric use is limited by need for longer acquisition time and greater need for patient cooperation.
  • In younger children, the need for sedation for MRI introduces additional logistical challenges and potential airway risks.

Differential Diagnosis

  • Peritonsillar cellulitisMost common diagnostic considerationAlso referred to as "phlegmon " Can be distinguished by the lack of classic peritonsillar abscess findings: peritonsillar space fullness, uvular deviation, and trismus
  • Retropharyngeal abscessMinimal to no peritonsillar findingsWidened prevertebral space on lateral neck radiographThis airway-compromising disease usually occurs in preschool children, not adolescents.
  • EpiglottitisThis life-threatening airway emergency presents abruptly with fever, stridor, increased work of breathing, and drooling.Usually occurs in toxic-appearing children 3 " “7 years oldRare entity in children since the advent of the Haemophilus influenzae type b vaccine
  • Other infectious causes of severe tonsillopharyngitis:EBV (infectious mononucleosis), coxsackievirus (herpangina), Corynebacterium diphtheriae, and Neisseria gonorrhoeae
  • Most common diagnostic consideration
  • Also referred to as "phlegmon " 
  • Can be distinguished by the lack of classic peritonsillar abscess findings: peritonsillar space fullness, uvular deviation, and trismus
  • Minimal to no peritonsillar findings
  • Widened prevertebral space on lateral neck radiograph
  • This airway-compromising disease usually occurs in preschool children, not adolescents.
  • This life-threatening airway emergency presents abruptly with fever, stridor, increased work of breathing, and drooling.
  • Usually occurs in toxic-appearing children 3 " “7 years old
  • Rare entity in children since the advent of the Haemophilus influenzae type b vaccine
  • EBV (infectious mononucleosis), coxsackievirus (herpangina), Corynebacterium diphtheriae, and Neisseria gonorrhoeae

Treatment

Medication

  • Clindamycin or ampicillin/sulbactam are the most commonly used 1st-line antibiotics, owing to their efficacy versus GABHS, Staphylococcus, and anaerobes.
  • As methicillin-resistant S. aureus isolates continue to increase, clindamycin is becoming more popular as drug of choice.
  • Some initiate therapy with high-dose IV penicillin " ”in the presence of a positive strep antigen or throat culture study.
  • Nafcillin, oxacillin, and cefazolin are acceptable antibiotic alternatives.
  • SteroidsSome experts recommend steroids to decrease swelling, pain, and trismus.Most evidence from adult rather than pediatric studiesMethylprednisolone, dexamethasone, and prednisone all have been used.
  • Some experts recommend steroids to decrease swelling, pain, and trismus.
  • Most evidence from adult rather than pediatric studies
  • Methylprednisolone, dexamethasone, and prednisone all have been used.

Additional Treatment

  • Abscesses should be urgently/emergently drained via either needle aspiration or surgical incision and drainage.
  • Antibiotic therapy as above
  • Steroid therapy recommended by some.
  • Appropriate analgesia and adequate hydration should be ensured in all cases.

Surgery/Other Procedures

  • As mentioned earlier, either needle aspiration or surgical incision and drainage is mandatory in the acute setting for true abscesses.
  • Most surgeons currently prefer interval tonsillectomy after the acute infection has been managed with antibiotics and an acute drainage procedure (needle aspiration or I&D).
  • Surgical drainage with tonsillectomy is considered in children not responding to parenteral antibiotics within 24 " “48 hours.
  • Acute or "hot "  tonsillectomy (also "quinsy tonsillectomy " ) is advocated by some.

Ongoing Care

Follow-up Recommendations

  • Patients may be discharged on oral antibiotics to complete a 10 " “14-day course when afebrile and peritonsillar swelling has subsided.
  • Tonsillectomy should be considered after severe or recurrent peritonsillar abscesses.

Prognosis

  • Complete recovery with appropriate therapy.
  • Recurrence of the abscess may occur.

Complications

  • Upper airway obstruction is the most feared complication.
  • Dehydration from decreased oral intake is the most common complication, however.
  • Abscesses left untreated can rupture spontaneously into the pharynx, leading to aspiration and pneumonia.
  • Other serious complications include parapharyngeal abscess, jugular vein suppurative thrombophlebitis (Lemierre syndrome), cavernous sinus thrombosis, sepsis, brain abscess, meningitis, and dissection into the internal carotid artery.
  • Even after appropriate drainage, a small number (10 " “15%) of peritonsillar abscesses may reform.

Additional Reading

  • Hayward ‚ G, Thompson ‚ MJ, Perera ‚ R, et al. Corticosteroids as standalone or add-on treatment for sore throat. Cochrane Database Syst Rev. 2012;10:CD008268. ‚ [View Abstract]
  • Maroldi ‚ R, Farina ‚ D, Ravanelli ‚ M, et al. Emergency imaging assessment of deep neck space infections. Semin Ultrasound CT MR. 2012;33(5):432 " “442. ‚ [View Abstract]
  • Powell ‚ J, Wilson ‚ JA. An evidence-based review of peritonsillar abscess. Clin Otolaryngol. 2012;37(2):136 " “145. ‚ [View Abstract]
  • Stoner ‚ MJ, Dulaurier ‚ M. Pediatric ENT emergencies. Emerg Med Clin North Am. 2013;31(3):795 " “808. ‚ [View Abstract]
  • Tagliareni ‚ JM, Clarkson ‚ EI. Tonsillitis, peritonsillar and lateral pharyngeal abscesses. Oral Maxillofac Surg Clin North Am. 2012;24(2):197 " “204, viii. ‚ [View Abstract]

Codes

ICD09

  • 475 Peritonsillar abscess

ICD10

  • J36 Peritonsillar abscess

SNOMED

  • 15033003 Peritonsillar abscess (disorder)

FAQ

  • Q: Are radiographs necessary to make the diagnosis of peritonsillar abscess?
  • A: No. The physical examination is diagnostic. A lateral neck radiograph, ultrasound, CT, or MRI are indicated only if the diagnosis is in question or to delineate extent of disease or additional complications.
  • Q: Is surgical consultation necessary in cases of peritonsillar abscess?
  • A: Yes. Otorhinolaryngology consultation is indicated for both acute as well as chronic management.