Peritonsillar Abscess

THE CASE: A 17-year-old boy hashad severe pharyngitis, fever, anddysphagia for the past 2 days. Althoughhe took an NSAID and triedgargling with hydrogen peroxide, heobtained no relief.

What is the most likely cause ofthe patient's symptoms?

• Mononucleosis
• Peritonsillar abscess
• Ludwig angina
• Epiglottitis

DISCUSSION:

The patient has aperitonsillar abscess, an inflammatoryprocess of the throat and tonsilsfirst described in the 14th century.Also known as quinsy, this infection isone of the most common inflammatoryprocesses of the head and neck region;the highest incidence occurs inpersons between the ages of 30 and40 years. Peritonsillar abscess formationis thought to result from a suppurativetonsillitis with an accumulationof pus in the peritonsillar tissues.Some evidence suggests that the infectiondevelopswithout any historyof tonsillitis.

Symptoms,which usuallymanifest severaldays before thepatient seeksmedical advice,include a unilateralsore throat,otalgia, neck discomfort,headache,dysphagia,malaise, and a"hot potato"voice. Oropharyngealexaminationusually revealsasymmetryof the soft palate;contralateral displacementof the uvula; and an enlarged,erythematous tonsil that oftenis covered with an exudate. Otherfindings may include trismus, drooling,adenopathy, fever, fetid breath,tachycardia, anxiety, and signs ofdehydration.

Laboratory and imaging studies(plain films, ultrasonography, orCT) are usually unnecessary unlessthe diagnosis is not evident or if deepspace infections of the neck are aconcern.

Mixed aerobic and anaerobic organismsare responsible for mostcases of peritonsillar abscess. Streptococcuspyogenes is the most commonlyreported aerobic organism; peptostreptococcalorganisms are the mostfrequently identified anaerobes.

Antibiotics are the mainstay oftherapy, although incision anddrainage may be necessary if the patientappears toxic or has significantswelling of the oral cavity. Admit patientswho appear toxic or who exhibitany signs of potential complications,such as airway obstruction. A combinationof a penicillin and metronidazoleis often recommended as initialtherapy because of the significant riskof streptococcal resistance and thepresence of mixed flora. Supportivetherapy with oral and parenteral analgesics,antipyretics, and hydration isindicated. Some experts recommendcorticosteroids to reduce discomfortand edema.

Patients with mononucleosisoften are between 15 and 25 yearsold, although this infection may affectyounger persons as well as elderlyones. Most cases are caused by infectionwith the Epstein-Barr virus.Patients typically have pharyngitis,fever, and lymphadenopathy that followsa 1- to 2-week prodrome of malaise,fatigue, and myalgia. Pharyngitismay be severe and is considered acardinal symptom of mononucleosis.Physical examination may reveal tonsillarerythema and edema with anexudate, cervical adenitis, splenomegaly,and a morbilliform or papular erythematouseruption on the trunk oran upper extremity rash.

Laboratory results that may behelpful in making the diagnosis includea white blood cell count and differentialthat demonstrate atypicallymphocytes, elevatedliver enzymes,and apositive heterophiletest. Supportivetherapyis the mainstayof treatment;analgesics, antipyretics,andbed rest arerecommended.

Ludwigangina is a rapidlyprogressivecellulitis that involvesthe submental,sublingual,and submandibularspaces. The softtissue is often describedas board-like. Secondary elevationand edema of the tongue resultin drooling and airway obstruction.Most of these infections are thoughtto have an odontogenic origin; thesecond and third molars are the mostcommon nidus of infection.

Ludwig angina is thought to becaused by hemolytic Streptococcus organisms,although a mixed Staphylococcus-Streptococcus infection or combinationof aerobic and anaerobic organismsmay be involved. Drainageand removal of necrotic material maybe warranted if antibiotic therapy isunsuccessful.

Epiglottitis results from an acuteinflammation of the epiglottis and surroundingsoft tissue, including thevallecula, aryepiglottic folds, and arytenoids.Haemophilus influenzae andgroup A streptococci are the mostcommon causal organisms in adults.This disease has historically beenseen in adults (average age, 45years), although in previous decades,it was more commonly described inchildren aged 3 to 7 years. With theadvent of the H influenzae type B vaccine,the incidence in children has declinedsignificantly.

Onset is acute. Symptoms,which progress rapidly, include dysphagia,pharyngitis, and hot potatovoice in a patient with no history ofupper respiratory tract infection.Other findings may include drooling,adenitis, stridor, toxic appearance,fever, and tripod posturing.

Empiric antibiotic therapy is institutedfor coverage of group A streptococci,Staphylococcus pyogenes, andH influenzae. Intubation equipmentshould be at the bedside and an otolaryngologistor anesthesiologist contactedemergently. If the patient is stable,lateral radiographs may help todelineate the clinical diagnosis. Visualizationof the airway should neverbe attempted in a child, because thismay cause acute airway obstructionresulting from laryngospasm.