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	Aerobic and anaerobic bacteria most common is Streptococcus pyogenes.	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.	On ultrasound peritonsillar abscess appears as focal irregularly marginated hypoechoic area.	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, Inspiratory stridor, expiratory wheezing, Sternal wall retractions	Mainly 6 months and 3 years old rarely, adolescents and adults	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.
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,	Fever, especially 100°F or higher.Erythema, edema and exudate of the tonsils, cervical lymphadenopathy, and Dysphonia.	Primarily affects children between 5 and 15 years old.	Intraoral or transcutaneous USG may show an abscess making CT scan unnecessary.	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)	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.	On CT scan, a mass impinging on the posterior pharyngeal wall with rim enhancement is seen	Immediate surgical drainage and antimicrobial therapy. emperic therapy involves; ampicillin-sulbactam or clindamycin.