PERITONSILLAR ABSCESS

Question 1

Approach to the Critically Ill Peritonsillar Abscess

Answer 1

Monitor
Oxygen
Vitals
IV Access
Equipment: Airway

AIRWAY
Rapid Bedside Assessment:
Drooling
Voice change
Stridor
Inability to speak
Tripod or sniffing positioning
Hypoxia
Swelling of the posterior oropharynx
Inability or unwillingness to lie flat

Position upright, head tilt / chin lift

Secure Airway in patients with impending airway obstruction

Awake / Nasal Intubation if Limited oral access

Fiberoptic Visualization > Video Laryngoscopy > Direct

Prepare for surgical airway PRIOR to non-surgical airway

Dexamethasone 0.6 mg / kg IV

Serial Airway Assessment

Abx: Peds
Ampicillin-sulbactam 50 mg/kg intravenous every 6 hours (maximum dose 3,000 mg)
OR
Clindamycin 15 mg/kg intravenous every 8 hours (maximum dose 900 mg)

Piperacillin-tazobactam (dose by age):
Age 2 months to 9 months: 80 mg/kg/dose (based on piperacillin component) intravenous every 8 hours (maximum dose 3,000 mg piperacillin)
Age >9 months, children, and adolescents weighing <40 kg: 100 mg/kg/dose (based on piperacillin component) intravenous every 6 hours (maximum dose 4,000 mg piperacillin)
Children and adolescents weighing >40 kg: 4,500 mg piperacillin intravenous every 6 hours

Urgent ENT Consult for further visualization/urgent nasopharyngeal scope/laryngoscopy in stable patients

BREATHING
Administer supplemental oxygen as needed for hypoxia and pre-oxygenation

CIRCULATION
Bolus 20 ml / kg Crystalloid if needed

Question 2

History & Physical

Answer 2

sore throat
odynophagia
voice change
Pooling of saliva
Trismus (up to 2/3 of patients)

fever
malaise

Unilateral tonsillary Swelling

Uvula displaced to the side

Question 3

Critical DDx

Answer 3

Angioedema
Foreign Body
Bacterial Tracheitis
Diphtheria
Epiglottitis
Lemierre Syndrome
Ludwig Angina
Mononucleiosis
Peritonsillar Abscess
Retropharyngeal Abscess
Uvulitis

Question 4

Investigations

Answer 4

Clinical Diagnosis

Consider:
CT Head and Neck with IV Contrast if diagnostic uncertainty, assess for complications or extent of Abscess

Ultrasound: intraoral or extraoral

Question 5

Steps for Needle Aspiration

Answer 5

22 Gauge Spinal Needle

Cut 1 cm off protective sheath

Anesthetic Spray

Laryngoscope

Suction

Aim for Superior Pole > Middle Pole > Inferior Pole

1 cm down an 1 cm in

Question 6

Management: Stable

Answer 6

Needle Aspiration

Incision & Drainage

Antibiotics:
Consider Ampicillin-sulbactam 50 mg/kg intravenous every 6 hours (maximum dose 3,000 mg)
OR
Clindamycin 15 mg/kg intravenous every 8 hours (maximum dose 900 mg)

Outpatient
Amoxicillin-clavulanate 45 mg / kg / dose PO bid
OR
Clindamycin 10 mg / kg / dose PO q 8 hours
10 to 14 days

Steroids:
Dexamethasone 0.6 mg / kg IV