Rosen & Barkin's 5-Minute Emergency Medicine Consult (536 page)

Rarely associated with airway emergencies, but diagnosis is likely to be uncertain in transport, so suction and intubation equipment should be at the bedside:

• Pulse oximetry, supplemental oxygen
  
• Cardiac monitor
  
• IV access
  

• PTA occurs in children (<18 yr) in 25–30% of reported cases (14 cases per 100,000 population)
  
• Young children may need sedation or general anesthesia if I&D or aspiration of the abscess is attempted
  
• Obtain soft-tissue lateral neck radiograph before oral exam in young children with symptoms of upper airway obstruction
  

• Same as for pre-hospital
  
• Airway management may be necessary
  
• Equipment for intubation and cricothyroidotomy should be available
  

• Antibiotics should be administered
  
• IV fluid should be given for dehydration
  
• Pain control is important
  
• A single dose of steroids may improve symptoms
  
• Adequate anesthesia prior to aspiration or I&D procedures is important:
  
  • Benzocaine spray
    
  • Lidocaine, 1% with 1:100,000 epinephrine
    
• No clear benefit for one drainage technique over another:
  
  • Needle drainage:
    
    • Successful 87–94%
      
    • Should be performed by a person experienced in drainage procedure and adept at advanced airway techniques
      
    • Less painful, less invasive than I&D
      
    • The internal carotid artery lies ∼2.5 cm posterolaterally to the tonsil; sheathing the aspiration needle to prevent introduction of the needle to <0.5 cm is prudent
      
    • The superior pole of the tonsil is the most common place for maximal fluctuance (followed by the middle pole and then the inferior pole)
      
    • Repeat aspiration is necessary in 10%
      
  • I&D:
    
    • Successful 90–92%
      
    • An 11- or 15-blade scalpel is used to make stab incision to area of fluctuance
      
    • Guard scalpel with trimmed plastic sheath leaving 1 cm of blade exposed
      
    • Avoid >0.5 cm depth
      
    • Medial and superior incisions are safer from the standpoint of potential injury to the carotid artery
      
    • Incision typically made superior to tonsil in area of soft palate. Incision in the tonsil itself causes excessive bleeding and may miss the abscess, which is located in the peritonsillar soft tissue of the soft palate.
      
    • Suction should be ready to remove purulent drainage and blood
      
    • Packing is
      not
      used
      
  • Tonsillectomy (indications in children):
    
    • Upper airway obstruction
      
    • Previous episodes of severe recurrent pharyngitis or PTA
      
    • Failure of abscess resolution with other drainage techniques
      
    • Can be performed immediately or after resolution of acute infection
      

• Length of antibiotic treatment should be 14 days (<10 day treatment course may be associated with recurrence)
  
• Adjunct with steroids can improve symptoms
  

• Ampicillin/Sulbactam (Unasyn), 3 gm q6h
  
• Penicillin G, 10 million U q6h + Metronidazole (Flagyl), 500 mg q6h
  
• If allergic to Penicillin, Clindamycin, 900 mg q8h
  

• Amoxicillin/Clavulanic acid (Augmentin), 875 mg BID
  
• Penicillin VK, 500 mg q6h + Metronidazole (Flagyl), 500 mg q6h
  
• Clindamycin, 600 mg BID or 300 mg q6h
  

• Dexamethasone, 10 mg IV/IM/PO single dose
  
  • Pediatrics: 0.6 mg/kg; not to exceed 10 mg
    
• Methylprednisolone, 2 mg/kg; not to exceed 250 mg
  

FOLLOW-UP

• Airway compromise
  
• Sepsis
  
• Altered mental status
  
• Dehydration and inadequate PO intake
  
• Extension of infection beyond the PTA (i.e., deep space neck infections)
  

• Most patients with PTA can be discharged home on oral antibiotics after abscess drainage
  
• Must be able to tolerate sufficient oral intake and antibiotics
  

• Referral to an otolaryngologist or surgeon should be provided
  
• Tonsillectomy is recommended 6–8 wk following treatment of the abscess
  

Close follow-up recommended in 24–48 hr:

• Treatment failures and recurrences are relatively common
  

• Failure to secure the airway early in a severe infection
  
• Failure to recognize a more advanced, deep space infection of the neck
  
• Knowing the anatomy before performing needle aspiration or bedside I&D
  
• Bedside US is a useful adjunct in differentiating and identifying a PTA vs. peritonsillar cellulitis
  

• Araujo Filho BC, Sakae FA, Sennes LU, et al. Intraoral and transcutaneous cervical ultrasound in the differential diagnosis of peritonsillar cellulitis and abscesses.
  Braz J Otorhinolaryngol
  . 2006;72:377–381.
  
• Brook I. Pediatric Peritonsillar Abscess,
  Medscape
  . Retrieved Dec 13, 2012 from
  http://emedicine.medscape.com/article/970260-overview
  .
  
• Costantino TG, Satz WA, Dehnkamp W, et al. Randomized trial comparing intraoral ultrasound to landmark-based needle aspiration in patients with suspected peritonsillar abscess.
  Acad Emerg Med
  . 2012;19:626–631.
  
• Marx JA, Hockberger RS, Walls RM, et al.
  Rosen’s Emergency Medicine: Concepts and Clinical Practice
  . 7th ed. St. Louis, MO: Mosby; 2009.
  
• Millar KR, Johnson DW, Drummond D, et al. Suspected peritonsillar abscess in children.
  Pediatric Emerg Care
  . 2007;23:431–438.
  
• Powell J, Wilson JA. An evidence-based review of peritonsillar abscess.
  Clin Otolaryngol.
  2012;37:136–145.
  
• Tan A. Peritonsillar Abscess in Emergency Medicine,
  Medscape
  . Retrieved Dec 13, 2012 from
  http://emedicine.medscape.com/article/764188-overview
  .
  
• Wald, Ellen, MD (2012). Peritonsillar cellulitis and abscess.
  UpToDate
  . Retrieved January, 2013 from
  http://www.uptodate.com/contents/peritonsillar-cellulitis-and-abscess
  .
  

• Epiglottitis
  
• Retropharyngeal Abscess
  

CODES

475 Peritonsillar abscess

BASICS

• Acute respiratory tract infection spread by small respiratory droplets
  
• Bacteria (fimbriae) attach to respiratory epithelial cells and proliferate, producing toxins:
  
  • Ciliary dysfunction, accumulation of cellular debris, increased mucus production, lymphocytic and granulocytic infiltration
    
• Bronchiolar congestion, obstruction, and necrosis
  
• Obstruction of the airway due to mucus plug, leading to hypoxia and hypoventilation
  
• Increased intrathoracic or intracranial pressure
  
• Secondary bacterial infection may exacerbate respiratory distress/failure.
  
• CNS injury caused by encephalitis, increased intracranial pressure, and/or hypoxia
  
• Uncomplicated cases last 6–10 wk; half of the cases last <6 wk.
  
• Mortality:
  
  • Mortality greatest in those <1 yr
    
  • 1.3% for patients <1 mo
    
  • 0.3% in children 2–11 mo
    
  • 90% of deaths are secondary to bacterial pneumonia
    
• Epidemiology:
  
  • Incubation period is 6–20 days, usually 7–10 days.
    
  • Mostly young children; 24% in children <6 mo
    
  • Increasing incidence in adolescents
    
  • Adults are the primary reservoir
    
  • Peak incidence is late summer/fall
    
  • Preventable with diphtheria–tetanus–pertussis (Tdap) vaccine
    

Bordetella pertussis
:

• A fastidious, gram-negative, pleomorphic bacillus
  

DIAGNOSIS

• Generally 3 recognized phases with progression:
  
  • Infants may have indistinct stages
    
• Catarrhal stage:
  
  • 1–2 wk duration
    
  • Rhinorrhea
    
  • Mild cough
    
  • Minimal fever
    
• Paroxysmal stage:
  
  • 1–6 wk duration
    
  • Classic “whooping” cough, increasing in severity:
    
    • Coughing spasm that ends with a sudden inflow of air—the whoop; unremitting paroxysms
      
  • Cyanosis with respiratory distress/failure
    
  • Apnea (infants <6 mo)
    
  • Altered mental status secondary to hypoxia or encephalitis
    
• Convalescent stage:
  
  • 2–12 wk duration
    
  • Waning cough
    
  • Improving respiratory status
    
• Atypical presentations:
  
  • Often atypical in children <6 mo
    
  • Partially immunized children have less severe disease
    
  • Adult manifestations are often only rhinorrhea, sore throat, persistent cough; often in family members