Peritonsilar Abscess - Dr. Winters

Anatomy 
- Internal carotid, sympathetic chain, IJ, cranial nerves - all pretty close in this small area

Risks for PTA
- smoking, bad teeth, chronic tonsillitis

Complications
- airway blockage, necrosis into carotid sheath, deep space infection, Lemierre's Syndrome

Imaging Indications
CT Scans should not be done routinely for PTA. PTA is primarily a clinical diagnosis.
Consider Contrasted CT in:
- toxic folks
- immuncompromised 
- concern for deep space spread
- Bilateral PTA (high extension rate)
- uncertain diagnosis

Ultrasound all PTA
- Helps to improve diagnostic accuracy.
- Helps to guide needle during aspiration.

When to Consult
- airway compromise
- gas producing organism or air fluid levels
- deep space infection
- failure to respond in 48-72 hrs of IV anbx; 
- if meet indications for quinsy tonsillectomy (removal of tonsils while PTA is present) 
     - Uncooperative patient
     - Pediatric patient 
     - Recurrent tonsillitis or PTA
     - Severe trismus

How to Drain

1. Apply anesthetic - 2 seconds of spray - hurricaine or cetacaine; atomize 4% lidocaine

2. Identify tonsil - use blood flow to help distinguish tonsil from abscess; Identify carotid

3. Supplies - need good lighting - bottom 1/2 of speculum or DL blade; 
     - needle - 18 gauge only need 1 cm unsheathed; consider spinal needle

4. Aspiration - Parallel to floor of the mouth; start at superior pole of tonsil - if you don' t get pus - then move to middle, then third pole - this is the only way needle aspiration is comparable to I&D; 
     - aspiration = less painful than I&D - speed of relief may be higher with I&D; ED literature rec's aspiration

Medical Management

1. Antibiotics - group A strep and anaerobe coverage

- Unasyn, Clindamycin, or Vancomycin (if life threatening or fail to respond)
   (everyone should get a dose of IV anbx)

- Oral 10-14 day course Pen VK QID plus flagyl 500 QID; clindamycin 300-450mg q 6 hrs; augmentin 45 mg/kg q12 
     - in young folks test for mono

2. Steroids - jury is still out; initially decreases pain but in 48-72 hrs no difference; use IV solumedrol

Disposition

1. 4-6 hrs observation, then DC if can tolerate PO; f/up in 24-48 hrs; gargle with H2O2 at least after each meal; soft diet and good oral hydration; antibiotics

2. Admit (23 hr obs on IV anbx) - peds; toxic; immuncompromised; can't tolerate PO

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