PANCE Blueprint EENT (9%)

Peritonsillar abscess (ReelDx)

VIDEO-CASE-PRESENTATION-REEL-DX

Peritonsillar abcess

Patient will present with → hot potato (muffled) voice and deviation of the uvula to one side. Drooling, fever, referred ear pain and odynophagia (difficulty swallowing)

It can present with a significant sore throat, pain with swallowing, trismus, deviation of the soft palate/ uvula, and muffled “hot potato” voice.

  • Deviation of the soft palate and asymmetric rise of the uvula are highly suggestive of abscess
  • Also known as a “Quincy's” abscess
  • It usually involves multiple bacteria. Streptococcusand Staphylococcus are the most frequent aerobic pathogens, whereas Bacteroides sp is the predominant anaerobic pathogen.

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

  • CT or ultrasonography of the neck 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.

Treatment involves aspiration, incision, and drainage, and/or antibiotics. Tonsillectomy may also be considered in about 10% of patients.

  • Examples of antimicrobial therapy include parenteral amoxicillin, amoxicillin-sulbactam, and 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
quinsy1

Quinsy abcess

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?
A
Recurrent streptococcal pharyngitis
Hint:
This presentation suggests a complication of an incompletely treated streptococcal pharyngitis rather than recurrent disease.
B
Infectious mononucleosis
Hint:
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.
C
Gonococcal pharyngitis
Hint:
Gonococcal pharyngitis usually follows a more indolent course than this patient's presentation.
D
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?
A
CBC with differential
Hint:
A CBC with differential would identify an infection but not specifically a retropharyngeal abscess.
B
fever and a muffled voice on examination
Hint:
The presence of fever and a muffled voice on physical exam is not specific for a retropharyngeal abscess.
C
CT of the neck with contrast
D
history of a recent throat infection
Hint:
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?
A
Needle aspiration
B
Corticosteroid administration
Hint:
Corticosteroids, nebulized epinephrine, and nasotracheal intubation are not indicated in the treatment of peritonsillar abscesses.
C
Nebulized epinephrine administration
Hint:
Corticosteroids, nebulized epinephrine, and nasotracheal intubation are not indicated in the treatment of peritonsillar abscesses.
D
Nasotracheal intubation
Hint:
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.
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