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Peritonsillar abscess (ReelDx + Lecture)


Peritonsillar abcess

47-year-old with pharyngitis and difficulty swallowing

Patient will present as → a 19-year-old male who you are seeing for follow-up from the urgent care, where he was seen 2 days earlier with a sore throat. The patient is febrile (102°F), has a muffled (hot potato) voice, and has extreme difficulty opening his mouth (trismus). He opens it just far enough for you to note uvular deviation.

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A peritonsillar abscess is a complication of tonsillitis and occurs when a collection of pus forms and spreads beyond the tonsils into the tissues of the throat next to one of the tonsils. Swollen tissues can block the airway

  • A peritonsillar abscess can present with a significant sore throat, pain with swallowing, trismus (inability to open the mouth normally), deviation of the soft palate/uvula, and muffled “hot potato” voice
  • Deviation of the soft palate and an asymmetric rise of the uvula is highly suggestive of abscess
  • Also known as “Quincy's” abscess
  • It usually involves multiple bacteria. Streptococcus and Staphylococcus are the most frequent aerobic pathogens, whereas Bacteroides sp is the predominant anaerobic pathogen

Xray, CT, or ultrasonography of the neck (which would show the collection of pus within the tissue) can help confirm the diagnosis when the physical examination is difficult, or the diagnosis is in doubt, particularly when the condition must be differentiated from a parapharyngeal infection or other deep neck infection

  • All such patients require needle aspiration of the tonsillar mass and cultures. Aspiration of pus differentiates abscess from cellulitis

Treatment is surgical drainage, antibiotics, and steroids, particularly in situations where there is a lot of inflammation that obstructs the airway

  • An initial 24-hour trial of appropriate parenteral antimicrobials (without surgical drainage) is justifiable in patients with presumed peritonsillar cellulitis who show no evidence of airway compromise, septicemia, severe trismus, or other complications
    • Examples of antimicrobial therapy include parenteral ampicillin-sulbactam and IV clindamycin
    • In less severe cases, oral antibiotics can be used for 7 to 10 days (i.e., amoxicillin, amoxicillin-clavulanate, clindamycin)
  • Secure the airway early in a severe infection
  • Tonsillectomy may also be considered in about 10% of patients (and those with recurrent peritonsillar abscess)

osmosis Osmosis
Question 1
An 18-year-old sexually active female was seen in the student health clinic 1 week ago for a sore throat. A streptococcal antigen test was positive, and she was given a prescription for oral penicillin. After 3 days, she stopped her medication because she felt better. She now presents with a severe sore throat. On physical examination, she has a temperature of 102.6° F (39.2° C), marked pharyngeal erythema, medial deviation of the soft palate on the left, tender left anterior cervical adenopathy, and a "hot potato" voice. The rest of her history and physical examination are unremarkable. Which of the following is the most likely diagnosis?
Recurrent streptococcal pharyngitis
This presentation suggests a complication of an incompletely treated streptococcal pharyngitis rather than recurrent disease.
Infectious mononucleosis
Infectious mononucleosis may present with severe sore throat, fever, and cervical adenopathy in this age group, but would not cause deviation of the soft palate or the muffled voice.
Gonococcal pharyngitis
Gonococcal pharyngitis usually follows a more indolent course than this patient's presentation.
Peritonsillar abscess
Question 1 Explanation: 
The soft palate deviation and a muffled voice are classic signs of peritonsillar abscess.
Question 2
Which of the following is most helpful in the diagnosis of a retropharyngeal abscess?
CBC with differential
A CBC with differential would identify an infection but not specifically a retropharyngeal abscess.
fever and a muffled voice on examination
The presence of fever and a muffled voice on physical exam is not specific for a retropharyngeal abscess.
CT of the neck with contrast
history of a recent throat infection
A recent throat infection is not specific for a retropharyngeal abscess.
Question 2 Explanation: 
CT of the neck is considered the "gold standard" for the diagnosis of a retropharyngeal abscess.
Question 3
A 14 year-old male presents with complaint of worsening sore throat for two weeks. He now complains of fever, difficulty swallowing, and difficulty opening his mouth. The patient's mother states his voice seems muffled. On examination his left tonsil is bulging and the uvula is displaced to the right. Which of the following is the most appropriate management?
Needle aspiration
Corticosteroid administration
Corticosteroids, nebulized epinephrine, and nasotracheal intubation are not indicated in the treatment of peritonsillar abscesses.
Nebulized epinephrine administration
Corticosteroids, nebulized epinephrine, and nasotracheal intubation are not indicated in the treatment of peritonsillar abscesses.
Nasotracheal intubation
Corticosteroids, nebulized epinephrine, and nasotracheal intubation are not indicated in the treatment of peritonsillar abscesses.
Question 3 Explanation: 
Surgical drainage by needle aspiration and antibiotic therapy is the treatment of choice for peritonsillar abscess.
There are 3 questions to complete.
Shaded items are complete.

References: Merck Manual · UpToDate

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