Ear, Nose & Throat
A 23 year old man presents to the Emergency Department with a 3 day history of sore throat. On examination you note peritonsillar swelling with shifting of the uvula away from the midline. You suspect a peritonsillar abscess. What organism is most likely the cause in this patient?
Answer:
Peritonsillar infection generally is preceded by tonsillitis or pharyngitis and progresses from pharyngitis to cellulitis to abscess. Smoking appears to be a risk factor. Peritonsillar abscesses are often polymicrobial. The predominant bacterial species are Streptococcus pyogenes (group A streptococcus [GAS]), Streptococcus anginosus, Staphylococcus aureus (including methicillin-resistant S. aureus [MRSA]), and respiratory anaerobes (including Fusobacteria, Prevotella, and Veillonella species).Peritonsillar Abscess
Ear, Nose & Throat
Last Updated: 12th February 2021
Peritonsillar abscess (PTA) usually occurs in the superior pole of the tonsil, manifested by a defined collection of pus between the tonsillar capsule, the superior pharyngeal constrictor muscle, and the palatopharyngeus muscle.
Pathophysiology
Peritonsillar infection generally is preceded by tonsillitis or pharyngitis and progresses from pharyngitis to cellulitis to abscess. Smoking appears to be a risk factor. Peritonsillar abscesses are often polymicrobial. The predominant bacterial species are Streptococcus pyogenes (group A streptococcus [GAS]), Streptococcus anginosus, Staphylococcus aureus (including methicillin-resistant S. aureus [MRSA]), and respiratory anaerobes (including Fusobacteria, Prevotella, and Veillonella species).
Diagnosis
The typical clinical presentation of PTA is a severe sore throat (usually unilateral), fever, and a "hot potato" or muffled voice. Pooling of saliva or drooling may be present. Trismus, related to irritation and reflex spasm of the internal pterygoid muscle, occurs in nearly two-thirds of patients; it helps to distinguish PTA from severe pharyngitis or tonsillitis. Patients often have neck swelling and pain and may have ipsilateral ear pain. Fatigue, irritability, and decreased oral intake may occur as a result of discomfort.
The presence of trismus may limit the ability to perform an adequate examination. If drooling is present, suggesting the possibility of epiglottitis, care must be taken not to be aggressive during the examination of the oral cavity. Examination findings consistent with PTA include an extremely swollen and/or fluctuant tonsil with deviation of the uvula to the opposite side. Alternatively, there may be fullness or bulging of the posterior soft palate near the tonsil with palpable fluctuance. Cervical and submandibular lymphadenopathy may be present in children with PTA.
Imaging is not necessary to make the diagnosis of PTA but may be necessary to differentiate PTA from peritonsillar cellulitis, deep neck space infections (e.g. retro- or parapharyngeal abscess), or epiglottitis.
Management
Prompt surgical intervention is indicated in patients who present with impending airway compromise, complications, enlarging masses, or significant comorbidities (e.g. immunodeficiency). Drainage (needle aspiration or incision and drainage), antimicrobial therapy, and supportive care are the cornerstones of management for PTA. Supportive care includes provision of adequate hydration and analgesia and monitoring for complications.
Complications
Complications of PTA may include:
- Airway obstruction
- Aspiration pneumonia if the abscess ruptures into the airway
- Septicaemia
- Internal jugular vein thrombosis
- Jugular vein suppurative thrombophlebitis (Lemierre syndrome)
- Carotid artery rupture
- Pseudoaneurysm of the carotid artery
- Mediastinitis
- Necrotising fasciitis
- Sequelae of group A streptococcus infection (when that organism is isolated)
Report A Problem
Is there something wrong with this question? Let us know and we’ll fix it as soon as possible.
Loading Form...
- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
