Peritonsillar abscess overview

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Differentiating Peritonsillar abscess from other Diseases

Epidemiology and Demographics

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Diagnosis

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Physical Examination

Laboratory Findings

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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 (PTA), also commonly referred to as quinsy, is defined as a collection of pus located between the tonsillar capsule and the pharyngeal constrictor muscles. It is the most common deep tissue infection of the neck.[1] Historically, it has been thought of as a complication of acute tonsillitis. However, recent studies have proposed additional hypothesis surrounding its pathogenesis making the understanding of the disease a medical dilemma.[2]

Historical perspective

In second and third century BC the treatment and pathogenesis of tonsillar pathology was first documented in literature by Celcius. In the 1930s and 1940s prior to the advent of antibiotics, surgical management was the most common treatment option for peritonsillar abscess. Interval tonsillectomy was mostly done after symptom resolution. By 1947, Chaud tonsillectomy or immediate surgical tonsillectomy became the treatment option.[3]

Classification

Peritonsillar abscess may be classified into 3 broad categories based on computed tomographical findings. These are based on the shape of the abscess, location of the abscess and shape and location of the abscess. This may be oval or cap, superior or inferior.[4]

Pathophysiology

The pathogenesis of peritonsillar abscess is still not well-understood.[2] Some authorities have proposed that peritonsillar abscess arises from blockage of drainage from tonsillar crypt following acute tonsillitis results in spread of infection into the peritonsillar space. However, others believe infectious process involving Weber's gland located in the supratonsillar space account for the abscess formation.[5][3][6][7] Antigenic response following any disturbance arising from within or around the tonsillar crypt mucosa allows for lymphocytic interaction. This disruption in the crypt epithelium may be preceded by infectious process. Invasion and proliferation of the tonsillar crypt by infectious pathogens results in localized edema and influx of neutrophils. This is clinically seen as inflamed tonsil with or without exudation.[5] Pus accumulation within tissue behind the supratonsillar space leads to tonsillar bulging, uvula and palate deviation.

Causes

The cause of peritonsillar abscess is usually polymicrobial. It is predominantly caused by aerobic and anaerobic bacteria.[8] Streptococcus pyogenes is the most common cause of peritonsillar abscess.[9][8][10][11] Other common causes include; Fusobacterium necrophorum, Streptococcus milleri, Staphylococci, Haemophilus, Fusobacterium, Prevotella, Acinetobacter, spp, Candida albicans, Peptostreptococcus spp., Pseudomonas spp., Enterobacter spp. and Klebsiella[9][8]

Differentiating Peritonsillar abscess from other Conditions

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.

Epidemiology and Demographics

The incidence of peritonsillar abscess is highest between November to December and April to May in the northern hemisphere. This has been associated with the highest rates of streptococcal pharyngitis and exudative tonsillitis around these times.[12][13] Peritonsillar abscess occurs in all age groups. The highest occurrence is in adults between 20 to 40 years of age.[1][14][15] There is no racial predilection to developing peritonsillar abscess. Males are more commonly affected with peritonsillar abscess than female with male to female ratio of approximately 1.4:1. However, equal male to female ratios have been reported as well.[16][17][18][19][20][21][22]

Screening

There are no screening recommendations for peritonsillar abscess.

Risk Factors

Common risk factors in the development of peritonsillar abscess include smoking, previous peritonsillar abscess episodes, history of recurrent pharyngotonsillitis (Inflammation of the pharynx and tonsils) and poor oral hygiene.[23][24]

Natural History, Complications and Prognosis

Peritonsillar abscess if left untreated may result in extraperitonsillar extension.[25][26] Peritonsillar abscess may be complicated by airway obstruction, aspiration pneumonitis or lung abscess secondary to peritonsillar abscess rupture, hemorrhage from erosion or septic necrosis into carotid sheath, mediastinitis, poststreptococcal sequelae (e.g., glomerulonephritis, rheumatic fever) when infection is caused by Group A streptococcus, and necrotizing fasciitis[1][27][28][29][30] The prognosis of peritonsillar abscess is good with early and appropriate treatment.[31][32][33][34]

Diagnosis

History and Symptoms

Patients presenting with peritonsillar abscess may have a prior history of acute tonsillitis. Symptoms start appearing 2-8 days before the formation of abscess. Common symptoms of peritonsillar abscess include drooling, dysphagia, foul smelling breath, fever, headache, hoarseness, muffled voice (also called hot potato voice), odynophagia, otalgia, sore throat and stridor.[35][1]

Physical Examination

On physical examination, patients are usually acutely ill-looking and may have high temperature, muffled voice (also called "hot potato voice"), contralateral deflection of the uvula, the tonsil is generally displaced inferiorly and medially, facial swelling, tonsillar hypertrophy,, trismus, drooling, tenderness of anterior neck and tender submandibular and anterior cervical lymph node.s[1][36][3][37]

Laboratory Findings

The diagnosis of peritonsillar abscess may be made without the use of laboratory findings however, some nonspecific laboratory findings may be helpful. Complete blood count with differential usually shows leukocytosis with neutrophilic predominance. Serum electrolytes may be useful in patients presenting with dehydration. Gram stain, culture and sensitivity for sample after abscess drainage may yield the causative organism however, emperic therapy should be initiated without delaying for culture results. A routine throat culture for group A streptococcus may be helpful as well.[2][5][3][6][7]

X ray

X ray of the neck is not helpful in the diagnosis of peritonsillar abscess. The initial imaging of choice is ultrasound.[38]

Ultrasound

The diagnosis of peritonsillar abscess may be made without the use of imaging however, imaging options may help in differentiating peritonsillar abscess from other simialr conditions example, peritonsillar cellulitis, retropharyngeal abscess and epiglottitis. On ultrasound, peritonsillar abscess appears as focal irregularly marginated hypoechoic area.[39][40][41][42]

CT

CT scan is helpful in defining the characteristics of the abscess as well as to classify it. It also helps in guiding possible complications. Coronal contrast-enhanced CT scan of the neck may identify the peritonsillar abscess[39] however, the use of CT scan is associated with a clinically significant delay in time to an otolaryngology consultation, time to admission, and time to bedside procedure.[43] CT scan may show diffuse hypodense lesion with rim enhancement in the peritonsillar space.[44]

Treatment

Medical therapy

Parenteral therapy is the preferred first line route of administration until the temperature of the patient has settled and clinically improved and then switched to oral therapy to complete a 14-day course.[32] The preferred emperic therapy is ampicillin-sulbactam with clindamycinas alternative agent. For resistant gram-positive cocci infections intravenous vancomycin or linezolid is added to the above emperic therapy.[45]

Surgical therapy

Incision and drainage, or Tonsillectomy are surgical modalities in the management of peritonsillar abscess. tonsillectomy is oindicated in peritonsillar abscess in severe upper airway obstruction, previous episodes of severe recurrent pharyngitis or peritonsillar abscess and in unresolving peritonsillar abscess after antibiotics and incision and drainage.[46][47][48][49]

Prevention

There are no definite preventive measures for peritonsillar abscess, however, immunization against certain organisms in childhood may decrease the burden of peritonsillar abscess resulting from such infections.

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Galioto NJ (2008). "Peritonsillar abscess". Am Fam Physician. 77 (2): 199–202. PMID 18246890.
  2. ↑ 2.0 2.1 2.2 Powell EL, Powell J, Samuel JR, Wilson JA (2013). "A review of the pathogenesis of adult peritonsillar abscess: time for a re-evaluation". J Antimicrob Chemother. 68 (9): 1941–50. doi:10.1093/jac/dkt128. PMID 23612569.
  3. ↑ 3.0 3.1 3.2 3.3 Passy V (1994). "Pathogenesis of peritonsillar abscess". Laryngoscope. 104 (2): 185–90. doi:10.1288/00005537-199402000-00011. PMID 8302122.
  4. ↑ 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.
  5. ↑ 5.0 5.1 5.2 L. Michaels, H.B. Hellquist Ear, nose and throat histopathology (2nd ed.)Springer-Verlag, London (2001), pp. 281–286
  6. ↑ 6.0 6.1 Blair AB, Booth R, Baugh R (2015). "A unifying theory of tonsillitis, intratonsillar abscess and peritonsillar abscess". Am J Otolaryngol. 36 (4): 517–20. doi:10.1016/j.amjoto.2015.03.002. PMID 25865201.
  7. ↑ 7.0 7.1 Herzon FS, Martin AD (2006). "Medical and surgical treatment of peritonsillar, retropharyngeal, and parapharyngeal abscesses". Curr Infect Dis Rep. 8 (3): 196–202. PMID 16643771.
  8. ↑ 8.0 8.1 8.2 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.
  9. ↑ 9.0 9.1 Brook I (2004). "Microbiology and management of peritonsillar, retropharyngeal, and parapharyngeal abscesses". J Oral Maxillofac Surg. 62 (12): 1545–50. PMID 15573356.
  10. ↑ Snow DG, Campbell JB, Morgan DW (1991). "The microbiology of peritonsillar sepsis". J Laryngol Otol. 105 (7): 553–5. PMID 1875138.
  11. ↑ 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.
  12. ↑ Belleza WG, Kalman S (2006). "Otolaryngologic emergencies in the outpatient setting". Med Clin North Am. 90 (2): 329–53. doi:10.1016/j.mcna.2005.12.001. PMID 16448878.
  13. ↑ Bisno AL, Gerber MA, Gwaltney JM, Kaplan EL, Schwartz RH, Infectious Diseases Society of America (2002). "Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Infectious Diseases Society of America". Clin Infect Dis. 35 (2): 113–25. doi:10.1086/340949. PMID 12087516.
  14. ↑ Steyer TE (2002). "Peritonsillar abscess: diagnosis and treatment". Am Fam Physician. 65 (1): 93–6. PMID 11804446.
  15. ↑ Khayr W, Taepke J (2005). "Management of peritonsillar abscess: needle aspiration versus incision and drainage versus tonsillectomy". Am J Ther. 12 (4): 344–50. PMID 16041198.
  16. ↑ Ong YK, Goh YH, Lee YL (2004). "Peritonsillar infections: local experience". Singapore Med J. 45 (3): 105–9. PMID 15029410.
  17. ↑ Marom T, Cinamon U, Itskoviz D, Roth Y (2010). "Changing trends of peritonsillar abscess". Am J Otolaryngol. 31 (3): 162–7. doi:10.1016/j.amjoto.2008.12.003. PMID 20015734.
  18. ↑ Klug TE (2014). "Incidence and microbiology of peritonsillar abscess: the influence of season, age, and gender". Eur J Clin Microbiol Infect Dis. 33 (7): 1163–7. doi:10.1007/s10096-014-2052-8. PMID 24474247.
  19. ↑ Gavriel H, Lazarovitch T, Pomortsev A, Eviatar E (2009). "Variations in the microbiology of peritonsillar abscess". Eur J Clin Microbiol Infect Dis. 28 (1): 27–31. doi:10.1007/s10096-008-0583-6. PMID 18612664.
  20. ↑ Sunnergren O, Swanberg J, Mölstad S (2008). "Incidence, microbiology and clinical history of peritonsillar abscesses". Scand J Infect Dis. 40 (9): 752–5. doi:10.1080/00365540802040562. PMID 19086341.
  21. ↑ Hidaka H, Kuriyama S, Yano H, Tsuji I, Kobayashi T (2011). "Precipitating factors in the pathogenesis of peritonsillar abscess and bacteriological significance of the Streptococcus milleri group". Eur J Clin Microbiol Infect Dis. 30 (4): 527–32. doi:10.1007/s10096-010-1114-9. PMID 21086007.
  22. ↑ Costales-Marcos M, López-Álvarez F, Núñez-Batalla F, Moreno-Galindo C, Alvarez Marcos C, Llorente-Pendás JL (2012). "[Peritonsillar infections: prospective study of 100 consecutive cases]". Acta Otorrinolaringol Esp. 63 (3): 212–7. doi:10.1016/j.otorri.2012.01.001. PMID 22425204.
  23. ↑ Lehnerdt G, Senska K, Fischer M, Jahnke K (2005). "[Smoking promotes the formation of peritonsillar abscesses]". Laryngorhinootologie. 84 (9): 676–9. doi:10.1055/s-2005-870289. PMID 16142623.
  24. ↑ Dilkes MG, Dilkes JE, Ghufoor K (1992). "Smoking and quinsy". Lancet. 339 (8808): 1552. PMID 1351238.
  25. ↑ Coughlin AM, Baugh RF, Pine HS (2014). "Lingual tonsil abscess with parapharyngeal extension: a case report". Ear Nose Throat J. 93 (9): E7–8. PMID 25255362.
  26. ↑ Deeva YV (2015). "[SURGICAL TREATMENT OF TONSILLAR NECK PHLEGMON]". Klin Khir (7): 47–8. PMID 26591220.
  27. ↑ Goldenberg D, Golz A, Joachims HZ (1997). "Retropharyngeal abscess: a clinical review". J Laryngol Otol. 111 (6): 546–50. PMID 9231089.
  28. ↑ Stevens HE (1990). "Vascular complication of neck space infection: case report and literature review". J Otolaryngol. 19 (3): 206–10. PMID 2355414.
  29. ↑ Greinwald JH, Wilson JF, Haggerty PG (1995). "Peritonsillar abscess: an unlikely cause of necrotizing fasciitis". Ann Otol Rhinol Laryngol. 104 (2): 133–7. doi:10.1177/000348949510400209. PMID 7857015.
  30. ↑ Wenig BL, Shikowitz MJ, Abramson AL (1984). "Necrotizing fasciitis as a lethal complication of peritonsillar abscess". Laryngoscope. 94 (12 Pt 1): 1576–9. PMID 6594557.
  31. ↑ Powell J, Wilson JA (2012). "An evidence-based review of peritonsillar abscess". Clin Otolaryngol. 37 (2): 136–45. doi:10.1111/j.1749-4486.2012.02452.x. PMID 22321140.
  32. ↑ 32.0 32.1 Apostolopoulos NJ, Nikolopoulos TP, Bairamis TN (1995). "Peritonsillar abscess in children. Is incision and drainage an effective management?". Int J Pediatr Otorhinolaryngol. 31 (2–3): 129–35. PMID 7782170.
  33. ↑ Johnson RF, Stewart MG, Wright CC (2003). "An evidence-based review of the treatment of peritonsillar abscess". Otolaryngol Head Neck Surg. 128 (3): 332–43. doi:10.1067/mhn.2003.93. PMID 12646835.
  34. ↑ Herzon FS (1995). "Harris P. Mosher Award thesis. Peritonsillar abscess: incidence, current management practices, and a proposal for treatment guidelines". Laryngoscope. 105 (8 Pt 3 Suppl 74): 1–17. PMID 7630308.
  35. ↑ Ferri, Fred (2015). Ferri's clinical advisor 2015 : 5 books in 1. Philadelphia, PA: Elsevier/Mosby. ISBN 978-0323083751.
  36. ↑ Ferri, Fred (2015). Ferri's clinical advisor 2015 : 5 books in 1. Philadelphia, PA: Elsevier/Mosby. ISBN 978-0323083751.
  37. ↑ Nwe TT, Singh B (2000). "Management of pain in peritonsillar abscess". J Laryngol Otol. 114 (10): 765–7. PMID 11127146.
  38. ↑ Secko M, Sivitz A (2015). "Think ultrasound first for peritonsillar swelling". Am J Emerg Med. 33 (4): 569–72. doi:10.1016/j.ajem.2015.01.031. PMID 25737413.
  39. ↑ 39.0 39.1 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.
  40. ↑ Scott PM, Loftus WK, Kew J, Ahuja A, Yue V, van Hasselt CA (1999). "Diagnosis of peritonsillar infections: a prospective study of ultrasound, computerized tomography and clinical diagnosis". J Laryngol Otol. 113 (3): 229–32. PMID 10435129.
  41. ↑ 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.
  42. ↑ 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.
  43. ↑ Grant MC, Guarisco JL (2016). "Association Between Computed Tomographic Scan and Timing and Treatment of Peritonsillar Abscess in Children". JAMA Otolaryngol Head Neck Surg. 142 (11): 1051–1055. doi:10.1001/jamaoto.2016.2035. PMID 27533126.
  44. ↑ Chen Y, Yang Q, Wang T, Li J, Ye J, Liu X; et al. (2014). "[Application of enhanced CT in the differential diagnosis of peritonsillar abscess and intratonsillar abscess]". Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 49 (2): 131–5. PMID 24742512.
  45. ↑ Principles and Practice of Pediatric Infectious Diseases, 4th ed, Long SS, Pickering LK, Prober CG (Eds), Elsevier Saunders, New York 2012. p.205.
  46. ↑ Windfuhr JP (2016). "Indications for tonsillectomy stratified by the level of evidence". GMS Curr Top Otorhinolaryngol Head Neck Surg. 15: Doc09. doi:10.3205/cto000136. PMC 5169082. PMID 28025609.
  47. ↑ Mcleod R, Brahmabhatt P, Owens D (2016). "Tonsillectomy is not a procedure of limited value - the unseen costs of tonsillitis and quinsy on hospital bed consumption". Clin Otolaryngol. doi:10.1111/coa.12773. PMID 27754588.
  48. ↑ Windfuhr JP (2016). "[Evidence-based Indications for Tonsillectomy]". Laryngorhinootologie. 95 Suppl 1: S38–87. doi:10.1055/s-0041-109590. PMID 27128404.
  49. ↑ Rasp G (2015). "[Tonsillectomy]". Laryngorhinootologie. 94 (4): 218–9. doi:10.1055/s-0035-1548998. PMID 25837365.

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