Spotting Peritonsillar abscesses: Swollen Silence

-Case-
A 25-year-old man stumbles into the ED with a muffled voice and throat discomfort. He has a sore throat, trismus, drooling, and can barely open his mouth. When prompted, he points to the left side of his throat, where his uvula is pushed to the right, and he winces when you palpate his left tonsillar region. You’re already reaching for a tongue depressor and ultrasound probe…

-Evaluation-
Peritonsillar abscesses (PTAs) are the most common deep neck infection, typically affecting teens and young adults. It usually evolves from untreated or severe tonsillitis, progressing to a collection of pus between the tonsillar capsule and pharyngeal muscles.

Classic symptoms:

  • Severe sore throat (usually unilateral)
  • Trismus (inability to open mouth fully)
  • Muffled “hot potato” voice
  • Drooling and dysphagia
  • Uvular deviation away from the affected side
  • Tonsillar bulging +/- fluctuance

Diagnosis:

  • Clinical exam is often sufficient when classic features are present!
  • Intraoral ultrasound can confirm the diagnosis and assist in drainage, and it’s especially useful if you’re unsure or the anatomy is distorted
  • CT with contrast, similarly, is helpful when the diagnosis is uncertain or in cases where the patient has a limited oral opening or you’re concerned about deep neck space involvement

-Management-

  • Needle aspiration or incision and drainage is the mainstay of treatment in the ED. Don’t forget – always aspirate laterally to avoid the carotid artery!
  • Antibiotics:
    • Ampicillin-sulbactam or clindamycin IV for inpatients
    • Amoxicillin-clavulanate or clindamycin PO for outpatient follow-up
  • ENT consult if you’re unsuccessful with drainage, or the abscess is particularly large/posterior
  • Airway management is rarely needed, but be ready if there is significant swelling, drooling, or voice changes

-Fast Facts-

  • Peritonsillar abscesses peak in incidence between ages 15-30
  • Classic triad = sore throat, trismus, and muffled voice
  • Ultrasound can help confirm the diagnosis and guide aspiration

A PTA needs to be diagnosed and drained quickly to prevent complications and relieve the patient’s severe pain. When a patient sounds like they’re talking with a mouth full of marbles, act fast – this hot potato needs to be handled while it’s still hot!

Want to learn more? Read our in-depth study guide on this topic!

Cheers,

Tamir Zitelny, MD

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-References-

  1. Galioto NJ. Peritonsillar Abscess. Am Fam Physician. 2008;77(2):199-202.
  2. Herzon FS, Martin AD. Medical and surgical treatment of peritonsillar abscess: a prospective study of 63 patients. Laryngoscope. 1986;96(7):870-873. doi:10.1288/00005537-198607000-00008
  3. Gavriel H, Vaiman M, Kessler A. Adult peritonsillar abscess: CT versus ultrasound diagnosis. Am J Otolaryngol. 2010;31(3):165-170. doi:10.1016/j.amjoto.2009.03.003
  4. Steyer TE. Peritonsillar abscess: diagnosis and treatment. J Am Board Fam Pract. 2001;14(6):417-420.
  5. Battaglia M, Pavlidis D, Kerschner JE. Current management of peritonsillar abscess: a survey of otolaryngology training programs. Int J Pediatr Otorhinolaryngol. 2004;68(6):733-737. doi:10.1016/j.ijporl.2004.01.008
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