Parapharyngeal abscess: diagnosis,complications and management in adults

Parapharyngeal abscess may cause life-threatening complications. Peritonsillar abscess and tonsillitis may result in parapharyngeal abscess. Since the introduction of antibiotics, the incidence of parapharyngeal abscess secondary to tonsillitis and peritonsillar abscess has decreased dramatically. We present five cases of parapharyngeal abscess resulting from tonsillitis and peritonsillar infection extending to the parapharyngeal space in adult patients. Two were complicated by mediastinitis despite early treatment by wide spectrum antibiotics. We believe that early diagnosis and aggressive antibiotic treatment with early surgical drainage in cases associated with pus collection are the key points in preventing serious and fatal complications. We emphasize the diagnostic role of computerized tomography (CT) scan and the importance of early and proper drainage of these abscesses.     

Synergistic necrotizing cellulitis as a complication of peritonsillar abscess

Peritonsillar abscess, a complication of tonsillitis, is not uncommon. The usual treatment consists of needle aspiration or surgical drainage and antibiotic treatment. Tonsillectomy may be used in the management of this condition, either at the time of diagnosis or after an interval period. Severe complications of peritonsillar abscess are rare. Synergistic necrotizing cellulitis is a fulminant infection associated with spread along fascial plains, necrosis of connective tissue and muscle, and high mortality. It is usually otondogenic in origin in the cervicofacial area and occurs in debilitated or immune compromised patients. We discuss cervicofacial-necrotizing soft tissue disease and report an unusual case of extensive synergistic necrotizing cellulitis of the neck, chest, and shoulder as a result of a peritonsillar abscess.     

Peritonsillar abscess in children in the southern district of Israel

Objective

Peritonsillar abscess is the most common deep neck infection and still provides a challenge to care givers in terms of diagnosis and treatment in the pediatric population. This study reviews our experience over the years 2004-2007 at the Soroka University Medical Center in the southern district of Israel in treating children with peritonsillar abscess. We compared our results with data regarding peritonsillar abscess in adults.

Methods

We performed a retrospective chart review of 126 children diagnosed and proved to have a peritonsillar abscess. Data regarding: age, sex, ethnicity, number of patients per year, seasonality, prior history of tonsillar infection, prior antibiotic treatment, length of hospitalization, surgical treatment, bacterial results and in hospital antibiotic treatment was collected from the medical charts of the patients.

Results

The average age of children with peritonsillar abscess was 12.8 years. 92 patients (73%) were above 10 years of age. We did not find an increase in the number of children with peritonsillar abscess per year over the time period of the study. The number of patients with peritonsillar abscess was significantly higher in the autumn and spring, 79 (62.6%) patients did not have prior history of tonsillar infections and 64 (67.4%) children were treated with antibiotics prior to the diagnosis of an abscess. In 95 (75.4%) patients the drainage method was needle aspiration, in 30 (28.3%) patients incision and drainage was performed and only one patient underwent bilateral quinsy tonsillectomy (0.8%). The bacterial culture was negative in 37 (36.7%) patients. In 29 patients (45% of positive cultures) the causative organism was Streptococcus group A. Mixed culture was present in 10 (15.6%) patients, nine cultures (14%) were positive for anaerobes, alone or in combination with other pathogens. Eighty-one patients (64.2%) were treated with amoxicillin-clavulanate potassium, 24 (19%) received cefuroxime and 17 (13.5%) were treated with cefuroxime+ metronidazole. The average hospital stay was 3 days.

Conclusion

Peritonsillar abscess, a potentially life threatening infection, is similar in presentation and bacteriology in the pediatric and the adult population. Based on our review we conclude that peritonsillar abscess in children can be effectively treated by the same methods used in the adult population.     

Use of steroids in the treatment of peritonsillar abscess

Peritonsillar abscess is the most common deep infection of the head and neck that occurs in adults; the treatment of the disease remains controversial. A prospective study using a single high dose steroid treatment for peritonsillar abscess, was undertaken in 62 patients to determine the treatment's effectiveness in relieving symptoms such as fever, throat pain, dysphagia and trismus. All patients were randomly assigned to two groups: 28 patients received intravenous antibiotic therapy and a single dose placebo and 34 patients were treated with single use of high dose steroid in addition to intravenous antibiotic. Patients were hospitalized after needle aspiration and therefore their clinical courses and responses to therapy could be rigorously assessed. Comparison of clinical outcomes with respect to hours hospitalized, throat pain, fever, trismus were assessed between the two groups. Clinical outcomes revealed a statistically significant difference between the two groups (p < 0.01), indicating that single use of high dose steroid prior to antibiotic therapy is more effective than the use of an antibiotic alone. These results suggest that single intravenous use of steroid in addition to antibiotic therapy is an excellent choice for the management of peritonsillar abscess.     

Changing Face of Treatment of Peritonsillar Abscess

Changing trends in the treatment of peritonsillar abscess are demonstrated by this retrospective study of 74 patients treated from 1975 through 1980 by a standardized regimen. This included needle aspiration at three points, intravenous antibiotics, hydration, and pharyngeal douches. The patients ' ages ranged from 11 to 73 years. There were 45 males and 29 females. Needle aspiration was positive in 52 patients (70%) and repeat aspiration was necessary in 10% of patients. Tonsillectomy was performed in 42 patients. No recurrent peritonsillar abscesses occurred during the 1 to 5 year follow-up of the 32 patients who did not have tonsillectomy. Recurrent tonsillitis did occur in 4 of these patients and 3 of them had a past history of recurrent tonsillitis. The authors conclude that treatment of peritonsillar abscess should consist of needle aspiration, intravenous antibiotics and supportive measures. Interval tonsillectomy should be performed only when there is a history of recurrent tonsillitis or previous peritonsillar abscess.     

Advantages of otorhinolaryngologist performed transcervical ultrasonography in the management of peritonsillar abscess

ObjectivesPeritonsillar abscess (PTA) is a very common infection, in particular in pediatric and adolescent population. A distinction between peritonsillar cellulitis and abscess should be made to determine the appropriate treatment. Nonetheless, the difference cannot always be made on physical examination alone and often requires imaging by computed tomography (CT). Radiation exposure as well as the cost and waiting time question the use of CT in this pathology. We present our experience in the use of Transcutaneous Cervical Ultrasonography for the diagnosis and management of peritonsillar abscess in the adult population.Study designClinical-prospective.MethodsAdult patients were evaluated for suspicion of PTA. Clinical findings were documented and all patients underwent a Transcutaneous Cervical Ultrasonography performed by a second otorhinolaryngology specialist well versed in Ultrasonography without knowing the clinical history, details of the physical examination, or the suspected side. Ultrasonography findings were later compared with the clinical examination and outcome of the medical or surgical management.ResultsEight adult patients (range 18-53 year-old) were enrolled in the study. Six of them, had, ultrasonography findings compatible with a peritonsillar liquid collection underwent surgical drainage that confirmed and drained an abscess. On two patients, the ultrasonography images described an aspect of peritonsillar cellulitis that was managed conservatively and showed a favorable remission. No complications during stay or side effects or intolerance to the ultrasound were recorded.ConclusionTranscutaneous Cervical ultrasonography is a fast, useful tool, better tolerated than the intra-oral ultrasonography in diagnosing PTA. It avoids all irradiation exposure is much cheaper and the waiting time is shorter. Worth noting, is the richness of information pertaining the anatomy, vessels and abscess location and extension, for the surgeon performing the exam just prior to surgery. The efficiency and training of otorhinolaryngology specialists with this technique shows numerous promising benefits and deserves to be further developed.     

Intraoral ultrasound evaluation of peritonsillar abscess

Peritonsillar cellulitis and peritonsillar abscess are similar clinical entities with markedly different methods of treatment. Therefore, accurate diagnosis is paramount to appropriate treatment. This pilot study was designed to evaluate the sensitivity and specificity of intraoral ultrasound as a noninvasive method of differentiating abscess from cellulitis. Sixteen consecutive patients suspected of having peritonsillar abscess were prospectively evaluated with intraoral ultrasound. The results were confirmed with imaging or surgical drainage. Correct diagnoses were made in 9 (90%) of 10 abscesses and in 5 (83%) of 6 cases of cellulitis. Our results suggest that, while there is a learning curve for intraoral ultrasound, it is an accurate, noninvasive, and inexpensive tool to differentiate abscess from cellulitis. We believe that this will be a clinically useful technique in the future.     

Health costs and consequences: have UK national guidelines had any effect on tonsillectomy rates and hospital admissions for tonsillitis?

Tonsillectomy is a common therapeutic option in the management of recurrent tonsillitis. In 1999, the Scottish Intercollegiate Guidelines Network (SIGN) introduced SIGN 34 outlining appropriate indications for tonsillectomy. Following concerns of increasing hospital admissions for tonsillitis, in 2009 ENT UK suggested that too few tonsillectomies were being undertaken. This study analyses the effect the SIGN guidelines have had on trends in population rates of tonsillectomy and hospital admissions for tonsillitis and peritonsillar abscess in England, Scotland and Wales. A retrospective study was undertaken using the health databases of England, Scotland and Wales between 1999 and 2010. Tonsillectomy, acute tonsillitis and peritonsillar abscess were identified using national classification codes. Changes in rate of tonsillectomy and hospital admissions for tonsillitis and peritonsillar abscess were assessed using a linear regression model. 699,898 tonsillectomies were undertaken in the three national cohorts over the study period. Linear regression analysis suggested that implementation of SIGN 34 significantly reduced the population rate of tonsillectomy in England (p = 0.005) and Wales (p = 0.003) but not in Scotland (p = 0.24), and indicated there had been an increase in hospital admissions for acute tonsillitis in all cohorts (England p = 0.000008, Scotland p = 0.03, Wales p = 0.000005) and peritonsillar abscess in England (p < 0.05) and Wales (p = 0.03). SIGN 34 has reduced tonsillectomy rates in England and Wales but not in Scotland. This finding is associated with increasing hospital admissions for acute tonsillitis in all national cohorts, which may suggest that the current stipulated guidelines miss patients who would benefit from surgical intervention.     

Peritonsillar abscess: a life threatening disease--diagnostic and therapeutic aspects

BACKGROUND: Acute tonsillitis is an extremely common infection seen in children and adults. In most cases, the family doctor is initially consulted. Intratonsillar, peritonsillar and retrotonsillar abscesses are frequent complications in the course of tonsillitis. In those cases, oropharyngeal infection may lead to a descending process with consecutive mediastinitis as a life-threatening condition. PATIENTS AND METHODS: We report the case of a 67-year old man who died of a mediastinitis resulting from a peritonsillar abscess. Clinical findings, radiological diagnostics and antibiotic as well as surgical therapy are illustrated. RESULTS: The patient died due to a septic multi-organic failure despite aggressive antibiotic and surgical therapy by a combined enoral and cervical approach with thoracic drainage. DISCUSSION: Peritonsillar abscess is a potentially life-threatening complication of acute tonsillitis. This must be kept in mind and should therefore lead to an adequate and directed management of this pathology. We discuss the stepwise diagnosis and therapy within the framework of scientific literature.     

Peritonsillar abscess associated with infectious mononucleosis: retrospective study of three cases

Three cases with infectious mononuculeosis associated with peritonsillar abscess were reviewed. The initial diagnoses in these three cases were tonsillitis or peritonsillitis. However, infectious mononucleosis was suspected because of an elevation in aminotransferases and was later confirmed by elevations in the titers of antibodies for Epstein-Barr virus. Peritonsillar abscesses developed and surgical drainage was performed in all three cases. The present study suggests a higher incidence of peritonsillar abscess in patients with infectious mononucleosis than previously expected.     

Possible role of anti-inflammatory drugs in complications of pharyngitis. A retrospective analysis of 163 cases

ObjectivesComplications of pharyngitis (peritonsillar abscess, retropharyngeal abscess, and cervical cellulitis) are rare, but appear to be on the increase over recent years and many of these patients have been treated by anti-inflammatory drugs prior to admission. The purpose of this study was to review the current epidemiological data concerning these complications and investigate a possible correlation with anti-inflammatory drug use.Material and methodsA single-centre retrospective review of epidemiological, clinical and microbiological data was performed on the medical charts of patients hospitalised for peritonsillar abscess, retropharyngeal abscess or cervical cellulitis between 2005 and 2010.ResultsOver a six-year period, 163 patients were hospitalised for complications of pharyngitis, with a sex-ratio of 1.82 (104/57). The number of cases of peritonsillar abscess (PTA) increased from 13 to 28 cases per year from 2005 to 2010 and the number of cases of retropharyngeal abscess increased from three to six cases per year over the same period. The number of cases of cellulitis remained stable with an average of 1.82 cases per year. Each year, significantly more patients with an abscess were admitted to our unit with a history of anti-inflammatory drug use (13.3 ± 4.6) than without anti-inflammatory drug use (7.8 ± 4.3) (P < 0.01). Micro-organisms were identified in 80% of cases, with mixed strains in 73% of cases, Streptococcus in 72% of samples and Streptococcus pyogenes in 19% of cases of PTA. A favourable outcome was observed in all patients in response to medical and surgical treatment.ConclusionIn line with the literature, we observed an increasing incidence of complications of pharyngitis. The present series comprised significantly more patients admitted for PTA with a history of anti-inflammatory drug use. A multicentre prospective controlled study in Nantes on a large cohort is currently underway and will probably confirm these preliminary results.     

A clinical prospective study of peritonsillar abscess in children

Distinguishing peritonsillar abscess from cellulitis is an important clinical problem, particularly in children, who may require a general anesthetic for drainage of these abscesses. In order to identify those clinical factors most significant for peritonsillar abscess, we did a prospective study of 21 patients who presented with sore throat, fever, trismus, and tonsillar bulge; all symptoms that are consistent with the diagnosis of peritonsillar abscess. On admission, the following parameters were recorded: patient age, duration of sore throat, fever, white blood cell count, drooling, the degree of trismus (measured exactly as incisor-incisor distance), the degree of pharyngotonsillar bulge, and change in voice. After 24 to 48 hours of parenteral antibiotics, 12 patients (57%) had improved sufficiently and were continued on antibiotics until resolution (cellulitis group). Nine patients (43%) had no improvement and underwent surgery for drainage of the peritonsillar abscess (abscess group). At the end of the 18-month study period, the cellulitis and abscess groups were compared. On admission, no significant difference was found in age, duration of sore throat, fever, or white blood cell count. The pharyngotonsillar bulge was mild in 58% and moderate in 42% of the cellulitis group, while in the abscess group, the pharyngotonsillar bulge was mild in only 33% and moderate in 67%. After 24 to 48 hours of parenteral antibiotics, all patients in the cellulitis group had improvement of at least one symptom; whereas, all patients in the abscess group had no change or worsening of at least one symptom, including trismus, dysphagia, voice change, drooling, or pharyngotonsillar bulge. On admission, the precise measurement of trismus was not significantly different in the two groups (24.7 mm in cellulitis group vs. 22.5 mm in abscess group). However, after 24 hours of antibiotics, trismus averaged 7 mm more in the abscess group versus the cellulitis group (p less than 0.05).     

Peritonsillar abscess: Treatment with immediate tonsillectomy - 10 years of experience

Abstract Conclusion: Immediate tonsillectomy in patients with peritonsillar abscess is a safe and effective treatment that should be considered as an alternative to conventional incision and drainage. Objective: To assess the efficacy, safety, and microbiology of immediate tonsillectomy over 10 years, in patients with peritonsillar abscess. Methods: This was a retrospective study. We reviewed the clinical charts of patients diagnosed with peritonsillar abscess in Clínica Las Condes from September 2000 to August 2010, who were treated with immediate unilateral or bilateral tonsillectomy. The patients' epidemiological information, antibiotic therapy, laterality of the surgery, results of microbiological cultures, complications, and recurrences were recorded. Results: A total of 112 patients were studied, with a mean age of 24 years. There were no events of sepsis, and there were only four cases (3.6%) of postoperative bleeding, two of which resolved spontaneously. Only 29% of the patients required morphine pump-based analgesia in the postoperative period. The mean length of hospital stay was 3.4 days. Among the 28 unilateral tonsillectomies, 4 (14.2%) developed streptococcal tonsillitis and 2 (7.1%) were readmitted with a contralateral peritonsillitis: one cellulitis and one abscess that required drainage and tonsillectomy. The most frequently isolated microorganisms were gram-positive bacteria (Streptococcus pyogenes and other streptococci) and anaerobic bacteria (mainly Bacteroides spp. and Fusobacterium nucleatum).     

The use of ultrasound evaluation in the diagnosis of peritonsillar abscess.

Peritonsillar Abscess (PTA) and Peritonsillar Cellulitis (PTC) are very similar clinical conditions. The differential diagnosis between them is made by needle aspiration, a very painful and invasive method. This study was performed at the Department of Otolaryngology at the Clinical Hospital of S?o Paulo University Medical School. It's aim was to evaluate the use of ultrasound as a noninvasive and inexpensive method of diagnosis, differentiating abscess from cellulitis. Twenty-one consecutive patients with a clinical diagnosis of peritonsillar infection were evaluated in the emergency service with a probable diagnosis of PTA. These patients were evaluated with intraoral and percutaneous ultrasound. Needle aspiration was used to compare and confirm the diagnosis. The sensitivity was 92.3% and specificity was 62.3%. The authors conclude that ultrasound is a good method to evaluate the differences between PTA and PTC.     

Bilateral peritonsillar abscesses: a challenging diagnosis

Peritonsillar abscess is the most common complication of acute tonsillitis. Bilateral peritonsillar abscesses are much less common, and they may be more difficult to detect on physical examination because the oropharynx often appears to be symmetrical rather than asymmetrical, as is the case in unilateral abscess. Previous steroid treatment may also complicate the diagnosis by masking the signs and symptoms of abscess. We describe the case of a young woman who presented to the emergency department with relatively mild symptoms despite having large bilateral peritonsillar abscesses. We believe that her symptoms had been masked by previous steroid therapy. We also review the treatment and microbiology of peritonsillar abscess.     

Management of peritonsillar abscess

A prospective, randomized clinical trial was conducted on 60 patients with confirmed peritonsillar abscess to: (1) compare the safety and efficacy of permucosal needle aspiration with that of incision and drainage; (2) assess whether admission to hospital and treatment with intravenous antibiotics is necessary; (3) culture the pus obtained, in order to decide on a rational antibiotic regime. Of the 60 patients, 30 were randomized to the needle aspiration group, and 30 to the incision and drainage group. The initial success rate was 87 per cent (26 of 30 patients) with needle aspiration, and 90 per cent (27 of 30 patients) with incision and drainage. Two patients required hospital admission, for rehydration and intravenous antibiotics. The commonest organisms cultured were streptococci (62 per cent); 97 per cent of all patients responded to penicillin. This study indicates that most patients with peritonsillar abscess may successfully and safely be treated by permucosal needle aspiration, and oral penicillin, on an out-patient basis.     

The management of peritonsillar sepsis by needle aspiration

172 consecutive patients admitted with suspected unilateral peritonsillar sepsis were studied. Needle aspiration of the peritonsillar space was performed, and they were all then treated with intravenous antibiotics (usually benzylpenicillin). Any pus obtained was cultured. The aspiration was repeated if the patient was not improving after 24 h. A quantity of pus was aspirated at the first attempt from 91 patients (53%); 82 of these required no further aspiration but 7 required a further single aspiration and 2 required a further 2 aspirations before resolution of the sepsis. 71 of the 81 patients (88%) from whom pus had not been aspirated, and who were therefore initially considered to have peritonsillar cellulitis, required no further aspirations. However, 6 subsequently drained pus spontaneously and 4 produced a positive aspirate on a second occasion. Four patients required a change in their antibiotic therapy. We have found the combination of needle aspiration and parenteral antibiotics to be an effective treatment of peritonsillar sepsis. All patients were spared the unpleasant and painful experience of an incision and drainage procedure.     

Who ends up having tonsillectomy after peritonsillar infection?

We wanted to explore how many patients will undergo tonsillectomy during the first 5 years after peritonsillar abscess or peritonsillar cellulitis, and why. In addition we sought predictive factors as to who would benefit from tonsillectomy. Medical records of 809 patients with peritonsillar infection (ICD-10 J36) aged over six were analyzed, and data on the history of tonsil infections and differences in treatment were collected. Data on patients who underwent tonsillectomy during the next 5 years were compared with data on patients needing no tonsillectomy. An abscess or planned interval tonsillectomy was performed on 159 patients. Of the conservatively treated 7- to 16.9-year-old patients, 42.5% required surgery later, of those aged 17–29.9 years, 31.3%, and those over 30, 13.2% (p < 0.001). Previous tonsillar infections led to increased (p = 0.067) probability of delayed tonsillectomy. Re-opening of the abscess cavity at the polyclinics, use of broad-spectrum antibiotics in the acute phase of infection, or being an outpatient or inpatient had no influence on the probability of later surgery. Overall one-fourth of the patients with peritonsillar infection underwent tonsillectomy during the next 5 years, even without being originally planned. Young age and previous tonsillar infections caused increased probability of delayed tonsillectomy.     

Peritonsillar abscesses in children

A follow-up retrospective study was performed on 41 children who presented with peritonsillar abscesses from 1970–1980. The ages ranged from 3 to 16 years, with the mean age of 10 years. There were 26 females and 15 males. The abscesses were predominantly left-sided (28 vs. 13 right-sided) and the mean duration of symptoms was 3 days. Of the patients, 39% had been treated with antibiotics prior to the abscess development. Only 15% of the patients had a documented past history of exudative tonsillitis. Of the 41, 1 patient was lost to follow-up, and 11 underwent tonsillectomy for the abscess. Thus, 29 patients were reviewed who received no surgical therapy for their peritonsillar abscess other than incision and drainage. These patients were contacted for an interval history with a period of follow-up ranging from 6 months to 10 years. Only 2 of the 29 patients (7%) had recurrent abscesses. Two other patients (7%) had further recurrent bouts of exudative tonsillitis but not abscesses. These 4 children were in an initial group of 6 who had a prior history of documented tonsillitis. The incidence of recurrent peritonsillar abscesses reported in the literature has ranged from 7.6 to 16% in series which were comprised mainly of adults. The low incidence of recurrent abscesses (7%) in this series would indicate a need to reevaluate the indication for tonsillectomy for peritonsillar abscess in the pediatric age group. The authors recommend that tonsillectomy be performed in those children who present with a pervious history of documented tonsillitis or suffer a complication at the time of the first abscess (neck abscess or airway compromise).