APPROACH TO SORE THROAT & PERITONSILLAR ABSCESSMR 8/3/09J.Chen

General Approach

R/O Life Threatening causes R/O non-infectious causes Determine whether or not treatment is

required

Life Threatening Causes

Airway Compromise Sitting in sniffing position Toxic appearing Drooling Voice change Fever

Life Threatening Causes

Epiglottitis Retropharyngeal abscess Peritonsillar abscess Significant tonsillar hypertrophy Diphtheria

Management

NPO Supplemental O2 Consider airway adjunct (NP airway) IV access (if pt can tolerate) Anesthesia

Non-infectious Causes

Environmental Irritative pharyngitis

Smoke Dry air Chemicals

Trauma Burns

Foreign Body Retained Laceration to posterior pharynx

Non-infectious Causes

Allergic/Inflammatory Allergens causing chronic postnasal drip Eosinophilic esophagitis

Tumors Rare in pediatric population

Infectious Causes

Bacterial: Group A Beta Hemolytic Streptococcus Group C Strep Group G Strep Neisseria Gonorrhoeae Tularemia Chlamydia Mycoplasma Diptheria

Infectious Causes

Viral Causes Adenovirus Influenza Parainfluenza Epstein-Barr Virus Cytomegalovirus HIV

Stomatitis HSV Coxsackievirus

History

Drooling? Voice Change? Fever? Exposure? Foreign Body? Headache? Abdominal Pain? URI symptoms? Immunization status? Sexual activity?

Physical Exam

General Appearance Drooling Stridor LAD Pharyngeal erythema/exudate Asymmetric Enlargement of tonsillar pillar Deviation of uvula Cobblestoning of posterior pharyngeal

mucosa Vesicular or ulcerative lesions in oropharynx

Laboratory Aids

Throat Culture Lateral Neck X-ray CBC Monospot

Peritonsillar Abscess

Suppurative infection of the tissues adjacent to the palatine tonsil

Most common abscess of the head and neck

Background

Gradual onset Progression from peritonsillar cellulitis 2 mechanisms

Direct spread of inadequately treated bacterial tonsillitis

Abscess formed in a group of salivary glands (Weber glands) in the supratonsillar fossa

30 per 100,000 person/year (25-30% Pediatric)

Cause

Bacterial Growth often polymicrobial Aerobic organisms

Group A beta-hemolytic streptococcus pyogenes Staphlococcus aureus Alpha-hemolytic strep Coag-negative staph Streptococcus pneumoniae

Anaerobic organisms Gram neg bacilli

Provetella Bacteroides

Peptostreptococcus Fusobacterium

History

Sore Throat/Dysphagia 5-7 days Trismus (2nd to inflammation of internal

pterygoid muscle) Fever Drooling Muffled Voice Referred Ear Pain

Physical Exam

Asymettric swelling of the soft tissue lateral and superior aspect of tonsil

Fluctuant area palpable Uvula displaced to contralLateral sideSoft palate red/swollen

Physical Exam

Moderately uncomfortable appearing Febrile Potential resp distress Trismus Halitosis Cervical adenopathy

Laboratory Tests

CBC with diff-leukocytosis with neutrophil predominance

Needle aspiration for culture and sensativity

Imaging

CT scan Sensitivity 100%, Specificity 75% Abscess appears as low attenuation mass

with ring-enhancing wall US

Sensitivity 89%, Specificity 100% Intraoral approach prefered

Complications

Airway Compromise Aspiration of abscess contents Parapharyngeal abscess Sepsis Hemorrhage Contiguous spread to pterygomaxillary

space

Treatment

Hydration Analgesia Antibiotics

Admit patients for: Airway Compromise Dehydration, inability to take PO Poor Compliance Systemic complication Toxic Appearing Unclear diagnosis

Antibiotics

Augmentin (amox+clavulanate) is DOC Unasyn (amp+sulbactan) for inpatient Ceftriaxone and clindamycin or

imipenem for severe or complicated cases

Surgical Drainage

Needle Aspiration 90% success rate after one aspiration Another 5-10% after second Complications: resp distress, aspiration,

hemorrhage Contraindications: uncertain diagnosis,

uncooperative, very young, airway management problem

I&D Wider Drainage More Painful Containdications: same as needle

aspiration Tonsillectomy

Definitive Therapy May decrease overall duration of stay Requires OR and intubation