Clinical Presentation
Tonsillitis is one of the most common presenting complaints at sickcall for the 18 to
24 year old age group. A purulent exudate is commonly seen covering the tonsils and the
throat is usually erythemic. Peritonsillar abscess is a complication of acute tonsillitis.
Identification of the patient with a peritonsillar abscess is usually made by observation
alone. On exam the tonsillar fossa is bulging, red, and fluctuant to palpation. The uvula
deviates to the unaffected side. The classic clinical presentation can include
unilateral sore throat, ear pain, foul breath, trismus, inability to swallow saliva, and a
"hot potato" voice.
Management
Management of a peritonsillar abscess can be carried out as an outpatient depending
upon the status of hydration, degree of sepsis, and the patients ability for
self-care. The first priority is to decompress the pus within the abscess either by needle
aspiration (18-gauge spinal needle) or by formal incision and drainage (I&D). IV
fluids should be given to correct dehydration. Begin IV antibiotics (PenVK 1 to 2 million
units every 4 hours or Cleocin 600 mg IV every 8 hours).
Needle Aspiration
The landmarks for needle aspiration are as follows: from the uvula base draw a line
laterally to the intersection of a line drawn posteriorly, parallel and medial to the
maxillary molars. Insert the 18 gauge spinal needle and aspirate as you advance to a depth
of 2 cm. If you fail to obtain pus, draw back and try again more inferiorly or more
medially along the tonsillar pillar.
Incision and Drainage (I&D)
The following supplies should be gathered to perform a formal I&D: a Yankauer
suction , #12 curved blade on a long handle, long hemostat, and culture swabs. After
injection with local anesthetic, incise the anterior pillar in a curvilinear line from the
base of the uvula to the area posterior to the last mandibular molar staying on the
anterior tonsil pillar. After incision of the mucosa use blunt dissection with a hemostat
spreading the tissues of the peritonsillar space until the abscess is entered. Give one
large spread with the hemostat to open the abscess and suction the pus. Don't forget
cultures. In some instances, an abscess is not found despite blunt dissection. Often a
peritonsillar cellulitis is the only pathology. In this case I&D is also beneficial
and speeds recovery by decompressing the tissues.
Post drainage care
After the pus is evacuated by needle or formal I&D, ensure the
patient is on high dose antibiotics as described above. As well as vigorous saline gargles
hourly. Maintain IV hydration, analgesia, and have the patient return in 24 hours to be
evaluated. Re-open the abscess pocket to assure complete drainage. Resolution of symptoms
are rapid after appropriate treatment. Continued symptoms beyond 48 hours indicate
incomplete drainage, a persistent abscess, or a misdiagnosis. In this instance, consider
mononucleosis and obtain a monospot. Institute steroid therapy - the response is often
dramatic after a single dose of steroids. An otolaryngology consultation to recommended
for a patient that has had a peritonsillar abscess.
Reference
-
DeWeese and Saunders Textbook of Otolaryngology.
Prepared by LCDR David A. Bianchi, MC, USN, Department of Otolaryngology,
National Naval Medical Center, Bethesda, MD. Reviewed by CAPT David H. Thompson, MC, USN,
Department of Otolaryngology, National Naval Medical Center, Bethesda, MD. (1998).