Peritonsillar abscess differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Prince Tano Djan, BSc, MBChB [2]

Overview

Peritonsillar abscess must be differentiated from other upper respiratory diseases and conditions that may cause throat pain and airway obstruction. These include; croup(laryngotracheobronchitis), pharyngitis, tonsilitis, retropharyngeal abscess and epiglottitis.

Differential diagnosis

Peritonsillar abscess must be differentiated from other upper respiratory diseases and conditions that may cause throat pain and airway obstruction as shown in the table below:

Disease/Variable Presentation Causes Physical exams findings Age commonly affected Imaging finding Treatment
Peritonsillar abscess Severe sore throat, otalgia fever, a "hot potato" or muffled voice, drooling, and trismus[1] Aerobic and anaerobic

bacteria most common is

Streptococcus

pyogenes.[2][3][4][5]

Contralateral deflection of the uvula,

the tonsil is displaced inferiorly and medially, tender submandibular and anterior cervical lymph nodes, tonsillar hypertrophy with likely peritonsillar edema.

The highest occurrence is in adults between 20 to 40 years of age.[1] On ultrasound peritonsillar abscess appears as focal irregularly marginated hypoechoic area.[6][7][8][9][6][7] Ampicillin-sulbactam, Clindamycin, Vancomycin or Linezolid
Croup Has cough and stridor but no drooling. Others are Hoarseness, Difficulty breathing, symptoms of the common cold, Runny nose, Fever Parainfluenza virus Suprasternal and intercostal indrawing,[10] Inspiratory stridor, expiratory wheezing, Sternal wall retractions[11] Mainly 6 months and 3 years old

rarely, adolescents and adults[12]

Steeple sign on neck X-ray Dexamethasone and nebulised epinephrine
Epiglottitis Stridor and drooling but no cough. Other symptoms include difficulty breathing, fever, chills, difficulty swallowing, hoarseness of voice H. influenza type b,

beta-hemolytic streptococci, Staphylococcus aureus,

fungi and viruses.

Cyanosis, Cervical lymphadenopathy, Inflamed epiglottis Used to be mostly found in

pediatric age group between 3 to 5 years,

however, recent trend favors adults

as most commonly affected individuals

with a mean age of 44.94 years

Thumbprint sign on neck x-ray Airway maintenance, parenteral Cefotaxime or Ceftriaxone in combination with Vancomycin. Adjuvant therapy includes corticosteroids and racemic Epinephrine.[13][14]
Pharyngitis Sore throat, pain on swallowing, fever, headache, abdominal pain, nausea and vomiting Group A beta-hemolytic

streptococcus.

Inflamed pharynx with or without exudate Mostly in children and young adults,

with 50% of cases identified

between the ages of 5 to 24 years

_ Antimicrobial therapy mainly penicillin-based and analgesics.
Tonsilitis Sore throat, pain on swallowing, fever, headache, and cough Most common cause is

viral including adenovirus,

rhinovirus, influenza,

coronavirus, and

respiratory syncytial virus.

Second most common

causes are bacterial;

Group A streptococcal

bacteria[15]

Fever, especially 100°F or higher. Erythema, edema and exudate of the tonsils,[16] cervical lymphadenopathy, and Dysphonia.[17][18] Primarily affects children

between 5 and 15 years old.

Intraoral or transcutaneous USG may show an abscess making CT scan unnecessary.[19][17][18] Antimicrobial therapy mainly penicillin-based and analgesics with tonsilectomy in selected cases.
Retropharyngeal abscess Neck pain, stiff neck, torticollis, fever, malaise, stridor, and barking cough Polymicrobial infection.

Mostly; Streptococcus

pyogenes, Staphylococcus aureus and respiratory anaerobes (example; Fusobacteria, Prevotella,

and Veillonella species)[20][21][22][2][23][24]

Child may be unable to open the mouth widely. May have enlarged cervical lymph nodes and neck mass. Mostly between 2-4 years, but can occur in other age groups.[25][26] On CT scan, a mass impinging on the posterior pharyngeal wall with rim enhancement is seen[27][28] Immediate surgical drainage and antimicrobial therapy. emperic therapy involves; ampicillin-sulbactam or clindamycin.

References

  1. 1.0 1.1 Galioto NJ (2008). "Peritonsillar abscess". Am Fam Physician. 77 (2): 199–202. PMID 18246890.
  2. 2.0 2.1 Brook I (2004). "Microbiology and management of peritonsillar, retropharyngeal, and parapharyngeal abscesses". J Oral Maxillofac Surg. 62 (12): 1545–50. PMID 15573356.
  3. Megalamani SB, Suria G, Manickam U, Balasubramanian D, Jothimahalingam S (2008). "Changing trends in bacteriology of peritonsillar abscess". J Laryngol Otol. 122 (9): 928–30. doi:10.1017/S0022215107001144. PMID 18039418.
  4. Snow DG, Campbell JB, Morgan DW (1991). "The microbiology of peritonsillar sepsis". J Laryngol Otol. 105 (7): 553–5. PMID 1875138.
  5. Matsuda A, Tanaka H, Kanaya T, Kamata K, Hasegawa M (2002). "Peritonsillar abscess: a study of 724 cases in Japan". Ear Nose Throat J. 81 (6): 384–9. PMID 12092281.
  6. 6.0 6.1 Lyon M, Blaivas M (2005). "Intraoral ultrasound in the diagnosis and treatment of suspected peritonsillar abscess in the emergency department". Acad Emerg Med. 12 (1): 85–8. doi:10.1197/j.aem.2004.08.045. PMID 15635144.
  7. 7.0 7.1 Boesen T, Jensen F (1992). "Preoperative ultrasonographic verification of peritonsillar abscesses in patients with severe tonsillitis". Eur Arch Otorhinolaryngol. 249 (3): 131–3. PMID 1642863.
  8. Bandarkar AN, Adeyiga AO, Fordham MT, Preciado D, Reilly BK (2016). "Tonsil ultrasound: technical approach and spectrum of pediatric peritonsillar infections". Pediatr Radiol. 46 (7): 1059–67. doi:10.1007/s00247-015-3505-7. PMID 26637999.
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  10. Johnson D (2009). "Croup". BMJ Clin Evid. 2009. PMC 2907784. PMID 19445760.
  11. Giordano S, Adamo P, Monaci F, Pittao E, Tretiach M, Bargagli R (2009). "Bags with oven-dried moss for the active monitoring of airborne trace elements in urban areas". Environ Pollut. 157 (10): 2798–805. doi:10.1016/j.envpol.2009.04.020. PMID 19457602.
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  13. Nickas BJ (2005). "A 60-year-old man with stridor, drooling, and "tripoding" following a nasal polypectomy". J Emerg Nurs. 31 (3): 234–5, quiz 321. doi:10.1016/j.jen.2004.10.015. PMID 15983574.
  14. Wick F, Ballmer PE, Haller A (2002). "Acute epiglottis in adults". Swiss Med Wkly. 132 (37–38): 541–7. PMID 12557859.
  15. Putto A (1987). "Febrile exudative tonsillitis: viral or streptococcal?". Pediatrics. 80 (1): 6–12. PMID 3601520.
  16. Stelter K (2014). "Tonsillitis and sore throat in children". GMS Curr Top Otorhinolaryngol Head Neck Surg. 13: Doc07. doi:10.3205/cto000110. PMC 4273168. PMID 25587367.
  17. 17.0 17.1 Nogan S, Jandali D, Cipolla M, DeSilva B (2015). "The use of ultrasound imaging in evaluation of peritonsillar infections". Laryngoscope. 125 (11): 2604–7. doi:10.1002/lary.25313. PMID 25946659.
  18. 18.0 18.1 Fordham MT, Rock AN, Bandarkar A, Preciado D, Levy M, Cohen J; et al. (2015). "Transcervical ultrasonography in the diagnosis of pediatric peritonsillar abscess". Laryngoscope. 125 (12): 2799–804. doi:10.1002/lary.25354. PMID 25945805.
  19. Kawabata M, Umakoshi M, Makise T, Miyashita K, Harada M, Nagano H; et al. (2016). "Clinical classification of peritonsillar abscess based on CT and indications for immediate abscess tonsillectomy". Auris Nasus Larynx. 43 (2): 182–6. doi:10.1016/j.anl.2015.09.014. PMID 26527518.
  20. Cheng J, Elden L (2013). "Children with deep space neck infections: our experience with 178 children". Otolaryngol Head Neck Surg. 148 (6): 1037–42. doi:10.1177/0194599813482292. PMID 23520072.
  21. Abdel-Haq N, Quezada M, Asmar BI (2012). "Retropharyngeal abscess in children: the rising incidence of methicillin-resistant Staphylococcus aureus". Pediatr Infect Dis J. 31 (7): 696–9. doi:10.1097/INF.0b013e318256fff0. PMID 22481424.
  22. Inman JC, Rowe M, Ghostine M, Fleck T (2008). "Pediatric neck abscesses: changing organisms and empiric therapies". Laryngoscope. 118 (12): 2111–4. doi:10.1097/MLG.0b013e318182a4fb. PMID 18948832.
  23. Wright CT, Stocks RM, Armstrong DL, Arnold SR, Gould HJ (2008). "Pediatric mediastinitis as a complication of methicillin-resistant Staphylococcus aureus retropharyngeal abscess". Arch Otolaryngol Head Neck Surg. 134 (4): 408–13. doi:10.1001/archotol.134.4.408. PMID 18427007.
  24. Asmar BI (1990). "Bacteriology of retropharyngeal abscess in children". Pediatr Infect Dis J. 9 (8): 595–7. PMID 2235179.
  25. Craig FW, Schunk JE (2003). "Retropharyngeal abscess in children: clinical presentation, utility of imaging, and current management". Pediatrics. 111 (6 Pt 1): 1394–8. PMID 12777558.
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  28. Vural C, Gungor A, Comerci S (2003). "Accuracy of computerized tomography in deep neck infections in the pediatric population". Am J Otolaryngol. 24 (3): 143–8. PMID 12761699.

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