Morning Report: 1/16/2015

Here’s Dr. Adal with today’s Morning Report!

 

Peritonsillar Abscess

 

Differential Diagnosis:

Tonsillitis, Pharyngitis, Epiglottitis, Paratonsillar Cellulitis, PTA, RPA, PPA, Diptheria, Ludwigs angina, Uvulitis, Mononucleosis, Acute HIV, Carotid Aneurysm.

 

Epidemiology: Most common deep space infection of the neck. Young adults in winter and early spring.

 

Pathogenesis: Polymicrobial infection, but GAS predominates. Progression of tonsillitis-cellulitis-abscess, or following inflammation of Weber glands. Can occur in patients with tonsillectomy. Complications if left untreated: airway obstruction, hemorrhage of carotid artery, extension of infection, aspiration, Pseudoaneurysm, CN IX,X,XII palsy.

 

Symptoms: Sore throat, odynophagia, fever, malaise, ipsilateral otalgia

 

Signs: Uvular deviation, muffled voice, trismus, foul smelling breath, lymphadenitis

 

Diagnosis: Clinical, needle aspiration, ultrasound, CT scan, lateral neck X-ray

 

Treatment: Steroids, Antibiotics (GAS, staph, resp anaerobes), Aspiration, I&D, tonsillectomy

 

Aspiration: Patient cooperative w/o severe trismus. Upright position. Topical and local anesthesia w/epi (25g needle), aspiration in sagittal plane with 18 gauge needle, 12ml syringe, suction.

 

I&D: No.11 blade with 0.5cm exposed, approach in sagittal plane, Kelly clamp –> loculations, no packing

 

Disposition: Observation of airway and ability to tolerate po . ENT consult if patient not improving. Admission if immunocompromised, septic, young child, severe trismus, complications, not able to tolerate po. If discharged, antibiotics for 10 days, with outpatient f/u in 24-36 hours. Recurrence 9-22%.

 

References:

Chapter 241. Infections and Disorders of the Neck and Upper Airway: Rupali N. Shah; Trinitia Y. Cannon; Carol G. Shores. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, Seventh edition.

 

Otolaryngologic Procedures Ralph J. Riviello. Roberts and Hedges’ Clinical Procedures in Emergency Medicine, Sixth edition. Chapter 63, 1298-1341

 

Powell, J., & Wilson, J. A. (2012). An evidence‐based review of peritonsillar abscess. Clinical Otolaryngology, 37(2), 136-145.

 

Lyon, M., & Blaivas, M. (2005). Intraoral ultrasound in the diagnosis and treatment of suspected peritonsillar abscess in the emergency department. Academic emergency medicine, 12(1), 85-88.

 

Costantino, T. G., Satz, W. A., Dehnkamp, W., & Goett, H. (2012). Randomized Trial Comparing Intraoral Ultrasound to Landmark‐based Needle Aspiration in Patients with Suspected Peritonsillar Abscess. Academic Emergency Medicine, 19(6), 626-631.

The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.
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Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital

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