Peritonsillar Abscess - Standard Treatment Guidelines

Peritonsillar abscess is a common infection of Head & Neck region. Although not generally considered as a deep neck space infection physicians must be aware of the typical clinical presentation & diagnostic strategies in order to quickly diagnose & appropriately treat these patients to prevent complications.

Ministry of Health and Family Welfare, Government of India has issued the Standard Treatment Guidelines for Peritonsillar Abscess. Following are the major recommendations :

Case Definition:

PTA is a collection of pus between the fibrous capsule of the tonsil usually at the upper pole & the superior constrictor muscles of pharynx.

Incidence in our Country : 0.9/10000/yr (Age Range- 3-91 yrs)

Differential Diagnosis

1. Infectious - Peritonsillar Cellulitis

Parapharyngeal abscess

Dental - Upper 3rd molar abscess

Co-existing Infectious Mononucleosis

2. Inflammatory - Kawasaki disease

3. Vascular - Post traumatic Internal Carotid Artery Aneurysm

4. Benign lesions - Benign Lympho-epithelial Cysts

5. Neoplastic – Large tonsil tumours with extra tonsillar spread (eg. Squamous cell carcinoma); Tonsillar lymphoma; Rhabdomyosarcoma

6. Peritonsillar space tumours-Minor Salivary gland tumours

7. Anterior Pillar Mucosal tumours-Squamous cell carcinoma

Prevention and Counselling

1. Do not smoke.

2. Maintain good oral hygiene

3. Promptly treat oral infections.

4. If recurrent tonsillitis, tonsillectomy can be considered.

5. Always finish the course of antibiotics given in prescription even if you feel better within few days of starting the course.

Optimal Diagnostic Criteria & Investigations

*Situation 1: At Secondary Hospital / Non Metro situation: Optimal standards of treatment in situations where technology & resources are limited

Clinical diagnosis

a) History

1. Progressive, usually unilateral sore throat over 3-4 days.


2. Odynophagia


3. Dysphagia for solids then liquids


4. Ipsilateral otalgia


5. Headache, body ache


6. Fever,chills& rigors

b) General Examination

1. Muffled & thick speech (hot potato voice / plummy voice)


2. Foul breath


3. Vitals – Fever; tachycardia

c) Local Examination

1. Limited mouth opening (Trismus)


2. Torticollis


3. Oral cavity- Dental caries


4. Oropharynx- Soft Palate-Congested ,Bulging

Anterior Tonsillar Pillar- Congested, Edematous

Tonsil-Edematous (May not appear enlarged as it gets buried in edematous pillars

Uvula-Edematous, pushed to opposite side.

Investigations

a) Complete Blood counts

b) Serum electrolytes

c) Needle aspiration of pus

1. Culture


2. Sensitivity

d) Imaging

1. Orthopantogram


2. X- Ray Neck

AP view – Distortion of soft tissue

Lateral view- Rule out other differential diagnosis

Treatment & Referral Criteria

Standard Operating Procedure

1. Needle Aspiration

• Infiltration of 2% Lignocaine with Adrenaline (1: 100,000) given.


• Using Needle 16-18 gauge & 10 ml syringe aspirate from the area which is most fluctuant.


• Aspirate at superior pole initially because it is the most common area where abscess is present; then middle 1/3rd followed by lower 1/3rd if pus is not returned from superior pole.


• Needle guard is used to prevent accidental injury to Internal Carotid Artery due to tip of needle migrating too far posteriorly. Only 0.5 cm of needle needs to be exposed.


• If needle guard is unavailable a curved clamp can be used to expose a small portion of needle before inserting it into area of aspiration.

2. Incision & Drainage

• Local infiltration of 2 percent Lignocaine with Adrenaline ( 1: 100,000) given.


• Using No.11 blade scalpel / Quinsy knife a large peritonsillar abscess is incised.


• It allows free flow of pus as the abscess cavity decompresses.


• To prevent risk of aspiration, allow patient to hold Yankauer catheter tip & do suction of pus.

3. Abscess /Hot Tonsillectomy

4. Interval Tonsillectomy

5. In-Patient Care

a) Airway- Tracheostomy may be essential in case of compromised airway

b) Breathing

c) Circulation- IV Fluids

d) Antibiotics- IV until acceptable swallowing is feasible.

e) Antibiotic of choice-

• Penicillin G Benzathine (Adult- 600mg iv q 6 hr for 12-24 hr Paediatric- 12,500- 25000 U/kg iv q 6hr)


• Erythromycin (Adult- 15-20 mg /kg/day PO /iv divided q6h; Not more than 4 g/day; Paediatric- 30-50mg/kg/day PO/iv divided q6h)

f) Analgesics- Paracetamol - 500 mg TDS; Pethidine

g) Hydrogen peroxide/ Saline mouth wash

h) Single dose iv Steroid

Out Patient Care

a) Analgesics

b) Antibiotics

c) Hydrogen peroxide gargles

*Situation 2: At superspeciality Facility in Metro Location Where Higher End Technology Is Available

Clinical Diagnosis -

a) History

1. Progressive, usually unilateral sore throat over 3-4 days.


2. Odynophagia


3. Dysphagia for solids then liquids


4. Ipsilateral otalgia


5. Headache, body ache


6. Fever,chills& rigors

b) General Examination

1. Muffled & thick speech (hot potato voice / plummy voice)


2. Foul breath


3. Vitals – Fever; tachycardia

c) Local Examination

1. Limited mouth opening (Trismus)


2. Torticollis


3. Oral cavity- Dental caries


4. Oropharynx- Soft Palate-Congested ,Bulging

Anterior Tonsillar Pillar- Congested, Edematous

Tonsil-Edematous (May not appear enlarged as it gets buried in edematous pillars

Uvula-Edematous, pushed to opposite side.

Investigations

a) Complete blood count

b) Serum Electrolytes

c) Monospot /Heterophile Antibody Test for Infectious Mononucleosis

d) Needle Aspiration of Pus - Culture & Sensitivity

e) Blood Culture - If Septicemia.

f) Imaging

1. Orthopantogram


2. X- ray Neck - AP view; Lateral view


3. CT-Scan Neck with Contrast

Indications for CT Scan

• Failure of I&D


• Presence of Trismus


• Young age (less than 7 yrs)

Findings in CT Scan

• Hypodense fluid collection with rim enhancement in tonsil.


• Foreign body (fish/chicken bone) as an inciting factor.

g) USG - Intraoral or Transcutaneous

h) MRI Angiography

Treatment

Standard Operating Procedure

1. Needle Aspiration

• Infiltration of 2% Lignocaine with Adrenaline (1: 100,000) given.


• Using Needle 16-18 gauge & 10 ml syringe aspirate from the area which is most fluctuant.


• Aspirate at superior pole initially because it is the most common area where abscess is present; then middle 1/3rd followed by lower 1/3rd if pus is not returned from superior pole.


• Needle guard is used to prevent accidental injury to Internal Carotid Artery due to tip of needle migrating too far posteriorly. Only 0.5 cm of needle needs to be exposed.


• If needle guard is unavailable a curved clamp can be used to expose a small portion of needle before inserting it into area of aspiration.

2. Incision & Drainage

• Local infiltration of 2 percent Lignocaine with Adrenaline ( 1: 100,000) given.


• Using No.11 blade scalpel / Quinsy knife a large peritonsillar abscess is incised.


• It allows free flow of pus as the abscess cavity decompresses.


• To prevent risk of aspiration, allow patient to hold Yankauer catheter tip & do suction of pus.

3. Abscess /Hot Tonsillectomy

4. Interval Tonsillectomy

5. In-Patient Care

a) Airway- Tracheostomy may be essential in case of compromised airway

b) Breathing

c) Circulation- IV Fluids

d) Antibiotics- IV until acceptable swallowing is feasible.

e) Antibiotic of choice-

• Penicillin G Benzathine (Adult- 600mg iv q 6 hr for 12-24 hr Paediatric- 12,500- 25000 U/kg iv q 6hr)


• Erythromycin (Adult- 15-20 mg /kg/day PO /iv divided q6h; Not more than 4 g/day; Paediatric- 30-50mg/kg/day PO/iv divided q6h)

f) Analgesics- Paracetamol - 500 mg TDS; Pethidine

g) Hydrogen peroxide/ Saline mouth wash

h) Single dose iv Steroid

Guidelines by The Ministry of Health and Family Welfare :

Dr J M Hans Ex-HOD Dept. of Otorhinolaryngology Dr.RML Hospital New Delhi