Thanks to Max W for presenting a case of a peritonsilar abscess in a patient with a hx of organ transplant who was found to have necrotizing HSV tonsillitis requiring incubation for subglottic/epiglottic edema
Peri-Tonsillar abscess in immunocompetent patients
(bread and butter)
This diagnosis can be made clinically based on suggestive sx – hot potato voice, pain with swallowing, 2/3 have truisms – and an exam with uvular deviation and a swollen tonsil.
- Annual incidence is 30/100,000 people with a peak onset during adolescence
- By contrast, appendicitis has an incidence of 233/100,000 people. Common enough that high volume emergency rooms see it on the regular but not as common as pneumonia.
- Risk factors include smoking, recurrent tonsillitis, and oropharyngeal cancer or radiation.
- Often progresses from exudative tonsillitis->tonsillar cellulitis->abscess
- Usually bacterial and polymicrobial with an over-representation of GAS, s milleri and anaerobes esp fusobacterium.
- Always consider the ddx of other deep neck space infections from mouth to mediastinum
- ludwig’s angina
- septic IJ thrombophlebitis (Lemierre’s disease)
- retropharyngeal abscess
- tracheal inflammation or infection
- Evaluate for impending airway compromise
- Difficulty managing secretions, voice changes, dyspnea. Stridor is a late sign
- Consider direct laryngoscopy if any concern.
- Aspirate that pus!
- We rarely admit paratonsilar abscesses. Usually ENT/the ED aspirates them, they get better and go home.
- Ultrasound can increase the yield of aspiration.
- If no pus is aspirated or symptoms do not improve, they should be admitted
- amox/clav and clinda are great PO options.
- Consider MRSA like you would in any other cellulitis. If so, they may need admission/IV vanc
- Small studies show evidence for a single dose of 10mg of dexamethasone to speed recovery.
PTA in severely immunocompromised patients
(ancient grains with caviar)
Main difference is in causative agents. Also consider…
- pseudomonas, MRSA, HSV (case-reportably rare, that’s what this patient had), candida (usually more slowly progressive.)
- initial abx management is often broad – don’t be afraid to call ID! This patient was started on vanc/piptazo/acyclovir.
- If pus cannot be aspirated, consider biopsy to guide dx therapy
- HSV tonsillitis improves with acyclovir.
References (and source of images)
Galioto NJ. Peritonsillar Abscess Am Fam Physician. 2017 Apr 15;95(8):501-506.
Hirzel C1, Nueesch S2, Wendland T3, Langer R4. Necrotizing herpes-simplex virus tonsillitis mimicking peritonsillar abscess. Infection. 2016 Apr;44(2):267-8.
Filed under: Morning Report