Rosen & Barkin's 5-Minute Emergency Medicine Consult (535 page)

• Amoxicillin clavulanate: 875 mg PO q12h or 500 mg PO q8h
  
• Ampicillin sulbactam: 1.5–3 g IV q6h
  
• Cefoxitin: 1–2 g IV q6–8h
  
• Clindamycin: 600–900 mg IV div. q8h
  
• Gentamicin: 3–6 mg/kg/d IV div. q8h
  
• Metronidazole: 7.5 mg/kg IV q6h
  

FOLLOW-UP

• Need for operative drainage
  
• Systemic toxicity/signs of sepsis
  

Adequate I&D with complete drainage

All should be referred to surgeon in 24--48 hr

Surgeon referral within 24–48 hr to evaluate for fistula:

• Fistulas develop in 25–50% of anorectal abscesses.
  

• Be certain of extent of abscess:
  
  • Thorough rectal exam and probing is mandatory.
    
  • Imaging adds insight into deeper areas not accessible to exam
    
• Deeper abscesses above dentate line have less pain and can present with isolated fever
  

• Marcus RH, Stine RJ, Cohen, MA. Perirectal abscess.
  Ann Emerg Med
  . 1995;25(5):597–603.
  
• Rizzo JA, Naig AL, Johnson EK. Anorectal abscess and fistula-in-ano: Evidence-based management.
  Surg Clin North Am
  . 2010;90(1):45–68.
  
• Schubert MC, Sridhar S, Schade RR, et al. What every gastroenterologist needs to know about common anorectal disorders.
  World J Gastroenterol
  . 2009;15:3201–3209.
  
• Steele SR, Kumar R, Feingold DL, et al. Practice parameters for the treatment of perianal abscess and fistula-in-ano.
  Dis Colon Rectum
  . 2011;54:1465–1474.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Abscess
  
• Anal Fissure
  
• Hemorrhoid
  

CODES

• 565.1 Anal fistula
  
• 566 Abscess of anal and rectal regions
  

BASICS

• Suppurative complication of tonsillitis where infection spreads outside the tonsillar capsule between the palatine tonsil and pharyngeal muscles
  
• Most common deep infection of the head and neck (incidence of 30/100,000 per year)
  
• In the US, 45,000 cases annually
  
• Occurs in all ages, more commonly in young adults (mean age 20–40 yr)
  
• Occurs most commonly Nov–Dec, April–May (coincides with highest incidence rates of streptococcal pharyngitis)
  
• Complications:
  
  • Airway compromise (uncommon)
    
  • Sepsis (uncommon)
    
  • Recurrence (12–15%)
    
  • Extension to lateral neck or mediastinum
    
  • Spontaneous perforation and aspiration pneumonitis
    
  • Jugular vein thrombosis (Lemierre syndrome)
    
  • Poststreptococcal sequelae (glomerulonephritis, rheumatic fever)
    
  • Hemorrhage from extension and erosion into carotid sheath
    
  • Severe dehydration
    
  • Intracranial extension (meningitis, cavernous sinus thrombosis, cerebral abscess)
    
  • Dural sinus thrombosis
    

• 2 theories explain the development of peritonsillar abscess (PTA):
  
  • Direct bacterial invasion into deeper tissues in the patient with acute pharyngitis
    
  • Acute obstruction and bacterial infection of small salivary glands (Weber glands) in the superior tonsil
    
• Smoking may be a risk factor
  
• Most common pathogens:
  
  • Group-A Streptococcus
    
  • Staphylococcal species, including methicillin-resistant
    Staphylococcus aureus
    (MRSA)
    
  • Anaerobes (
    Prevotella, Peptostreptococcus, Fusobacterium
    )
    
  • Polymicrobial
    

DIAGNOSIS

• Sore throat
  
• Fever
  
• Voice change
  
• Odynophagia (difficulty swallowing)
  
• Drooling
  
• Headache
  
• Pain radiating to the ear
  
• Decreased PO intake
  
• Malaise
  

• Fever
  
• Trismus
  
• “Hot potato” voice
  
• Erythematous tonsils/soft palate
  
• Inferior and medial displacement of superior pole of tonsil on affected side
  
• Uvular deviation away from affected side
  
• Halitosis
  
• Cervical lymphadenitis
  
• Tenderness on ipsilateral side of neck at the angle of the jaw
  

• Evaluation for deep space infections beyond the PTA, either with additional imaging or physical exam that may require admission and surgery
  
• Evaluate and ensure airway patency: Look for stridor, tripod position, or inability to handle secretions
  
• Definitive management with either needle aspiration or incision and drainage (I&D), followed by a course of antibiotics
  

• Usually a clinical diagnosis made by visually examining oropharynx
  
• May be difficult with severe trismus
  

• Throat culture and monospot (20% incidence of mononucleosis with PTA)
  
• CBC and culture of the abscess contents may be useful in some cases
  
• Basic metabolic panel may be useful in patients with decreased oral intake and clinical signs of dehydration
  

• Bedside intraoral US:
  
  • Using the high-frequency intracavitary US transducer with a lubricated latex cover can aid in identification and localization of the abscess
    
  • A cooperative patient can place the transducer at the point of maximum tenderness
    
• Transcutaneous cervical ultrasound is an option when the patient has too much trismus to use an intracavitary probe
  
• Soft-tissue lateral neck:
  
  • If suspicion for epiglottitis or retropharyngeal abscess exists
    
• Chest radiograph:
  
  • With severe respiratory symptoms or draining abscess
    
• CT scan of neck:
  
  • If suspicion exists for other deep space infection of the neck, CT may be indicated
    
  • CT also may be indicated if unable to obtain a good exam secondary to trismus
    
  • CT may locate abscess pocket after failed needle aspiration
    
• MRI may be useful to evaluate for complications of deep space infections (internal jugular vein thrombosis or erosion into the carotid sheath)
  

• Needle aspiration is diagnostic and often curative
  
• Bedside I&D
  

• Peritonsillar cellulitis
  
• Epiglottitis
  
• Retropharyngeal abscess
  
• Peripharyngeal abscess
  
• Tracheitis
  
• Meningitis
  
• Retropharyngeal hemorrhage
  
• Cervical osteomyelitis
  
• Cervical adenitis
  
• Epidural abscess
  
• Infectious mononucleosis
  
• Internal carotid artery aneurysm
  
• Lymphoma
  
• Foreign body
  
• Other deep space infections of the neck
  

TREATMENT