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Published on : Jun 04, 2015
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Slide 1 -

Approach to Sore Throat & Peritonsillar Abscess MR 8/3/09 J.Chen

Slide 2 -

General Approach R/O Life Threatening causes R/O non-infectious causes Determine whether or not treatment is required

Slide 3 -

Life Threatening Causes Airway Compromise Sitting in sniffing position Toxic appearing Drooling Voice change Fever

Slide 4 -

Life Threatening Causes Epiglottitis Retropharyngeal abscess Peritonsillar abscess Significant tonsillar hypertrophy Diphtheria

Slide 5 -

Management NPO Supplemental O2 Consider airway adjunct (NP airway) IV access (if pt can tolerate) Anesthesia

Slide 6 -

Non-infectious Causes Environmental Irritative pharyngitis Smoke Dry air Chemicals Trauma Burns Foreign Body Retained Laceration to posterior pharynx

Slide 7 -

Non-infectious Causes Allergic/Inflammatory Allergens causing chronic postnasal drip Eosinophilic esophagitis Tumors Rare in pediatric population

Slide 8 -

Infectious Causes Bacterial: Group A Beta Hemolytic Streptococcus Group C Strep Group G Strep Neisseria Gonorrhoeae Tularemia Chlamydia Mycoplasma Diptheria

Slide 9 -

Infectious Causes Viral Causes Adenovirus Influenza Parainfluenza Epstein-Barr Virus Cytomegalovirus HIV Stomatitis HSV Coxsackievirus

Slide 10 -

History Drooling? Voice Change? Fever? Exposure? Foreign Body? Headache? Abdominal Pain? URI symptoms? Immunization status? Sexual activity?

Slide 11 -

Physical Exam General Appearance Drooling Stridor LAD Pharyngeal erythema/exudate Asymmetric Enlargement of tonsillar pillar Deviation of uvula Cobblestoning of posterior pharyngeal mucosa Vesicular or ulcerative lesions in oropharynx

Slide 12 -

Laboratory Aids Throat Culture Lateral Neck X-ray CBC Monospot

Slide 13 -

Peritonsillar Abscess Suppurative infection of the tissues adjacent to the palatine tonsil Most common abscess of the head and neck

Slide 14 -

Background Gradual onset Progression from peritonsillar cellulitis 2 mechanisms Direct spread of inadequately treated bacterial tonsillitis Abscess formed in a group of salivary glands (Weber glands) in the supratonsillar fossa 30 per 100,000 person/year (25-30% Pediatric)

Slide 15 -

Cause Bacterial Growth often polymicrobial Aerobic organisms Group A beta-hemolytic streptococcus pyogenes Staphlococcus aureus Alpha-hemolytic strep Coag-negative staph Streptococcus pneumoniae Anaerobic organisms Gram neg bacilli Provetella Bacteroides Peptostreptococcus Fusobacterium

Slide 16 -

History Sore Throat/Dysphagia 5-7 days Trismus (2nd to inflammation of internal pterygoid muscle) Fever Drooling Muffled Voice Referred Ear Pain

Slide 17 -

Physical Exam Asymettric swelling of the soft tissue lateral and superior aspect of tonsil Fluctuant area palpable Uvula displaced to contral Lateral side Soft palate red/swollen

Slide 18 -

Physical Exam Moderately uncomfortable appearing Febrile Potential resp distress Trismus Halitosis Cervical adenopathy

Slide 19 -

Laboratory Tests CBC with diff-leukocytosis with neutrophil predominance Needle aspiration for culture and sensativity

Slide 20 -

Imaging CT scan Sensitivity 100%, Specificity 75% Abscess appears as low attenuation mass with ring-enhancing wall US Sensitivity 89%, Specificity 100% Intraoral approach prefered

Slide 21 -

Complications Airway Compromise Aspiration of abscess contents Parapharyngeal abscess Sepsis Hemorrhage Contiguous spread to pterygomaxillary space

Slide 22 -

Treatment Hydration Analgesia Antibiotics Admit patients for: Airway Compromise Dehydration, inability to take PO Poor Compliance Systemic complication Toxic Appearing Unclear diagnosis

Slide 23 -

Antibiotics Augmentin (amox+clavulanate) is DOC Unasyn (amp+sulbactan) for inpatient Ceftriaxone and clindamycin or imipenem for severe or complicated cases

Slide 24 -

Surgical Drainage Needle Aspiration 90% success rate after one aspiration Another 5-10% after second Complications: resp distress, aspiration, hemorrhage Contraindications: uncertain diagnosis, uncooperative, very young, airway management problem

Slide 25 -

I&D Wider Drainage More Painful Containdications: same as needle aspiration Tonsillectomy Definitive Therapy May decrease overall duration of stay Requires OR and intubation

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