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return to: Common Call Problems

see also: Tonsillectomy and Adenoidectomy

Evaluation

1. History:
   1. Sore throat
   2. Decreased oral intake due to progressive odynophagia 
   3. Drooling from inability to tolerate own secretions
   4. Fever
   5. Voice changes- "hot potato voice" 
   6. PMH: diabetes, medication allergies, recent trial of antibiotics
2. Physical exam 
   1. Airway assessment
   2. Trismus (sine qua non of PTA) - due to inflammation causing medial pterygoid spasm. 
   3. Asymmetry of soft palate with uvular deviation
   4. Neck ROM 
   5. Quality of voice
   6. Lymphadenopathy
3. Workup: 
   1. Labs: CBC
   2. Imaging
      1. Not required, but consider CT scan if significant decreased neck ROM with pain on turning, to assess posterior pharyngeal space involvement, or if findings are unusual (eg. bilateral swelling)
      2. CT: Look for a rim-enhancing fluid collection in the peritonsillar space
   3. Cultures are usually not obtained as they typically show oral flora
   4. Consider rapid Strep antigen testing

Management

1. Initial management
   1. IV antibiotic (eg. Unasyn 3 g, or clindamycin 900 mg if PCN allergic)
   2. IV fluid rehydration (eg. Lactated Ringers 1 L)
   3. IV steroids (eg. Decadron 10 mg)
      1. Hold if diabetic given effect on glucose
   4. Pain medication (eg. morphine/Dilaudid)
2. Optimum management of PTA is controversial. Options include:
   1. Needle aspiration only
   2. Incision and drainage
   3. Quincy tonsillectomy
3. Disposition: Often discharge home after drainage/tonsillectomy if patient can drink, is breathing well, not septic, and is not actively bleeding
4. Home Rx:
   1. Give elixir form if possible
   2. Oral antibiotic (eg. Augmentin 875 mg bid, or clindamycin 300mg tid if PCN allergic)
   3. Pain (eg. Lortab 5/500 1-2 tab po q4h)
   4. Saltwater rinses, soft diet for a few days
   5. Consider 2-3 days of 20-30mg prednisone

Drainage procedure

1. Anatomic considerations
   1. Target: abscess is usually superior to the tonsil, at the intersection of the base of the uvula and the anterior tonsillar pillar (see circled area in diagram below), and deep to the mucosa and palatoglossus muscle.
   2. The carotid is usually 2.0-2.5cm posterolateral to the target. 
      1. May consider bending the needle at 1.5cm or cutting off the a needle cap to expose only 1.5cm of needle
2. Equipment
   1. Hurricaine spray and/or 4% viscous lidocaine, 1% lidocaine with 1:100,000 epinephrine
   2. 3cc syringe with 18g needle (for drawing lidocaine) and 27g needle (for injection)
   3. Control top syringe with 18g needle
   4. #11 blade
   5. Hemostat
   6. Suction with Yankauer tip
   7. Headlamp
   8. Informed consent 
3. Patient positioning – operator preference
   1. Sitting 
   2. Lying (ref 1)
4. Local anesthesia
   1. Topical (eg. hurricaine spray, viscous lidocaine)
   2. Consider IV morphine, versed
   3. Inject 1% lidocaine with 1:100,000 to mucosa, then deeper into muscle
      1. Have Yankauer suction ready in case pus drains with injection so patient does not aspirate the pus
5. Needle drainage
   1. If pus drained with the lidocaine injection, aim for that area, otherwise aim for the target as described above. 
   2. Insert needle on control top syringe about 1cm, constantly pulling back while advancing. 
   3. Aspirate as much as possible. It may be necessary to redirect the needle to different angles, or try other spots.
   4. Remember to avoid directing the needle laterally and more than 2cm deep due to the carotid
6. Incision and drainage
   1. If an abscess pocket is identified, withdraw the needle and make an incision about 1cm long following the orientation of the arch.
   2. Spread in the pocket using hemostats and break up any septations.
   3. You can use the Yankauer tip to apply gentle pressure around the incision site to facilitate further drainage.
   4. Leave the hole open to allow for continued drainage
   5. Consider obtaining bacterial cultures
      1. Most common single organism implicated is S. pyogenes, however, cultures demonstrating mixed oral flora are quite common.

References

1. Chang and Hamilton. Novel technique for peritonsillar abscess drainage. Ann Otol Rhinol Laryngol (2008) vol. 117 (9) pp. 637-40