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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