Throat pain in a child will catch a parent’s attention, which, in turn leads to it catching your attention. Most often the parental concern is over whether this is due to Strep Throat or Mono. Naturally, there are a variety of other issues that we must consider. Perhaps this is merely a Tonsillolith. Of course, we also worry much more about Retropharyngeal Abscesses, Oropharyngeal trauma, and Lemierre’s Syndrome.  Yet, let us not overlook, the most common deep space infection in the neck: Peritonsillar Abscess.

Peritonsillar Abscess: Basics

• Peritonsillar abscess is the most common deep space head and neck infection.
  • In children, it accounts for 49% of head and neck infections. [Ungkanont, 1995]
  • Retrophayrngeal abscess account for 22%. [Ungkanont, 1995]
• Collection of pus located between the tonsillar capsule, the superior constrictor and the palatopharyngeus muscle. [Schraff, 2001]
• Complications:
  • Spread to other contiguous structures and into the parapharyngeal space and deeper.
  • Acute enlargement of the tonsillar pillars causing airway constriction!
  • Spontaneous rupture of tonsil and acute aspiration of purulent material. (yuk)

Peritonsillar Abscess: Diagnostic Challenge

• Peritonsillar Abscess should be a clinical diagnosis.
• The issue is when your clinical exam is limited!
  • Some children will not be the most cooperative with the exam.
    • Trimus (30-60% of the time) may actually prevent their cooperation. [Schraff, 2001; Ungkanont, 1995]
    • Small mouth opening can also obscure your view. [Brodsky, 1988]
  • May need to enhance your exam!
    • Positioning
      • Have child sit on parent’s lap, facing parent, with legs extended around parent’s waist.
      • Have child lay backwards onto parent’s legs, ideally so that head extends slightly over the parent’s knees.
      • This often leads to some “disorientation” and makes the mouth easier to open.
    • Tools
      • Ensure good lighting with headlamp (super cool looking too).
      • Tongue displacement and good lighting with Magill Laryngoscope (See ALIEM Tricks of Trade)
  • Often leads to potential over utilization of CT scans, especially in younger children. [Baker, 2012]
  • May require sedated exam in the OR or ED to more accurately make diagnosis. [Schraff, 2001]

Peritonsillar Abscess: Imaging

• Ideally the image you need is made with your eyeballs, but… if you need see better:
• Certainly CT is very sensitive [Scott, 1999], but comes with other issues.
  • CT is close to 100% sensitive.
  • Most useful if you are concerned for deeper space infection, like Retropharyngeal Abscess.
• Ultrasound
  • Intra-oral Ultrasound (using endocavitary probe)
    • Has been shown to be very specific.  [Scott, 1999]
    • Can be somewhat intimidating for children.
  • Trans-cervical Ultrasound (using linear, high frequency probe)
    • Tolerated well and is less intimidating (as there is no large probe being projected into the kid’s painful mouth).
    • Uses the submandibular and midline approaches. [See Bandarkar, 2015 for nice description]
    • Found to be helpful in determining who will not need surgical intervention. [Fordham, 2015]

Peritonsillar Abscess: Management

• Analgesia (please don’t be cruel).
• Optimize hydration status.
• Antibiotics
  • Coverage for Streptococcus species is necessary.
  • Don’t forget about Fusobacterium!
  • Often polymicrobial infections are present.
  • Some can even be treated with antibiotics alone. [Nguyen, 2015; Hsiao, 2011]
• Drainage of Abscess
  • Needle Aspiration
  • Incision and Drainage
    • There has been a trend favoring Incision and Drainage over Tonsillectomy. [Qureshi, 2015]
  • Quinsy Tonsillectomy
    • Tonsillectomy during acute infection.
  • Delayed / Interval Tonsillectomy
    • Tonsillectomy after resolution of infection.
    • Often reported to have less complications, but not necessarily true. [Simon, 2013]

Moral of the Morsel

• Peritonsillar Abscess is common so be familiar with its management.
• The diagnosis is primarily clinical, but the clinical exam can be challenging, so know how to augment your exam.
• If uncertain, start with ultrasound, preferentially starting with trans-cervical images!
• Realize that there are options for management that even include a trial of antibiotic only and reassessment (although I wouldn’t send that one home).
• In older, cooperative patients, it is completely reasonable to manage as you would an adult with Needle Aspiration in the ED.

References