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Approach to Sore Throat & Peritonsillar Abscess

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Presentation on theme: "Approach to Sore Throat & Peritonsillar Abscess"— Presentation transcript:

1 Approach to Sore Throat & Peritonsillar Abscess
MR 8/3/09 J.Chen

2 General Approach R/O Life Threatening causes R/O non-infectious causes
Determine whether or not treatment is required

3 Life Threatening Causes
Airway Compromise Sitting in sniffing position Toxic appearing Drooling Voice change Fever

4 Life Threatening Causes
Epiglottitis Retropharyngeal abscess Peritonsillar abscess Significant tonsillar hypertrophy Diphtheria

5 Management NPO Supplemental O2 Consider airway adjunct (NP airway)
IV access (if pt can tolerate) Anesthesia

6 Non-infectious Causes
Environmental Irritative pharyngitis Smoke Dry air Chemicals Trauma Burns Foreign Body Retained Laceration to posterior pharynx

7 Non-infectious Causes
Allergic/Inflammatory Allergens causing chronic postnasal drip Eosinophilic esophagitis Tumors Rare in pediatric population

8 Infectious Causes Bacterial: Group A Beta Hemolytic Streptococcus
Group C Strep Group G Strep Neisseria Gonorrhoeae Tularemia Chlamydia Mycoplasma Diptheria

9 Infectious Causes Viral Causes Stomatitis Adenovirus Influenza
Parainfluenza Epstein-Barr Virus Cytomegalovirus HIV Stomatitis HSV Coxsackievirus

10 History Drooling? Voice Change? Fever? Exposure? Foreign Body?
Headache? Abdominal Pain? URI symptoms? Immunization status? Sexual activity?

11 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

12 Laboratory Aids Throat Culture Lateral Neck X-ray CBC Monospot

13 Peritonsillar Abscess
Suppurative infection of the tissues adjacent to the palatine tonsil Most common abscess of the head and neck

14 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)

15 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

16 History Sore Throat/Dysphagia 5-7 days
Trismus (2nd to inflammation of internal pterygoid muscle) Fever Drooling Muffled Voice Referred Ear Pain

17 Physical Exam Asymettric swelling of the soft tissue lateral and superior aspect of tonsil Fluctuant area palpable Uvula displaced to contral Lateral side Soft palate red/swollen

18 Physical Exam Moderately uncomfortable appearing Febrile
Potential resp distress Trismus Halitosis Cervical adenopathy

19 Laboratory Tests CBC with diff-leukocytosis with neutrophil predominance Needle aspiration for culture and sensativity

20 Imaging CT scan US Sensitivity 100%, Specificity 75%
Abscess appears as low attenuation mass with ring- enhancing wall US Sensitivity 89%, Specificity 100% Intraoral approach prefered

21 Complications Airway Compromise Aspiration of abscess contents
Parapharyngeal abscess Sepsis Hemorrhage Contiguous spread to pterygomaxillary space

22 Treatment Hydration Analgesia Antibiotics Admit patients for:
Airway Compromise Dehydration, inability to take PO Poor Compliance Systemic complication Toxic Appearing Unclear diagnosis

23 Antibiotics Augmentin (amox+clavulanate) is DOC
Unasyn (amp+sulbactan) for inpatient Ceftriaxone and clindamycin or imipenem for severe or complicated cases

24 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

25 I&D Tonsillectomy Wider Drainage More Painful
Containdications: same as needle aspiration Tonsillectomy Definitive Therapy May decrease overall duration of stay Requires OR and intubation

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