Peritonsillar Abscess and Cellulitis

Abscess (quinsy) and cellulitis probably represent a spectrum of the same process in which bacterial infection of the tonsils and pharynx spreads to the soft tissues. Infection is virtually always unilateral and is located between the tonsil and the superior pharyngeal constrictor muscle. It usually involves multiple bacteria that include aerobes and anaerobes. Streptococcus and Staphylococcus species are the most frequent aerobic pathogens (1); Bacteroides species is the predominant anaerobic pathogen.

Peritonsillar Abscess With Uvular Deviation

Image

In this patient, the uvula is pushed away from the midline by the swollen tonsillar area, suggesting peritonsillar abscess or cellulitis. There are crypts on the swollen side.

DR P. MARAZZI/SCIENCE PHOTO LIBRARY

Symptoms include gradual onset of severe unilateral sore throat, dysphagia, fever, otalgia, and asymmetric cervical adenopathy. Trismus (lockjaw), a "hot potato" voice (speaking as if a hot object was in the mouth), a toxic appearance (eg, poor or absent eye contact, irritability, inability to be consoled or distracted, fever, anxiety), drooling, severe halitosis, tonsillar erythema, and exudates are common. Abscess and cellulitis both cause swelling above the affected tonsil, but abscess causes a more discrete bulge, with deviation of the soft palate and uvula and pronounced trismus.

• Needle aspiration

• Sometimes imaging (ultrasound, CT)

The diagnosis of peritonsillar abscess and cellulitis is primarily clinical; however, distinguishing abscess from cellulitis based on physical examination alone is challenging. Peritonsillar abscess and cellulitis are recognized in patients who have a severe sore throat and who have the following:

• Trismus

• "Hot potato" voice

• Uvular deviation

All such patients require needle aspiration of the tonsillar mass and cultures. The absence of pus on needle aspiration may indicate cellulitis (1).

Point-of-care ultrasound can be used for diagnosis and to determine the optimal location for aspiration or incision and drainage; sensitivity is high, but specificity is only moderate (2).

CT of the neck can help confirm the diagnosis when the physical examination is difficult or the diagnosis is in doubt, particularly when the condition must be differentiated from a parapharyngeal infection or other deep neck infection.

• Antibiotics

• Drainage of abscess

The treatment of peritonsillar abscess and cellulitis includes antibiotics that cover both aerobes and anaerobes along with supportive care (eg, hydration, pain control). Drainage (needle aspiration or incision and drainage) of the abscess is also required. Most patients can be managed in the outpatient setting.

Cellulitis subsides, usually within 48 hours, with hydration and high-dose penicillin (eg, 2 million units IV every 4 hours or 1 g orally 4 times a day) (1); alternative antibiotics include a first-generation cephalosporin (eg, 1-2 grams IV every 8 hours), amoxicillin (eg, 875 mg oral every 12 hours) or clindamycin. Culture-directed antibiotics are then prescribed for 10 days.

Abscesses are usually incised and drained in the emergency department using thorough local anesthesia and sometimes procedural sedation; low quality evidence suggests incision and drainage may be associated with a lower risk of recurrence compared with needle aspiration alone (2, 3). Ultrasound guidance is sometimes used when the diagnosis of abscess is unclear or when the abscess is small (< 1 cm). Although most patients can be treated as outpatients, some need brief hospitalization for parenteral antibiotics, IV hydration, and airway monitoring.

Rarely, an immediate tonsillectomy is performed, particularly in a young or uncooperative patient who has other indications for elective tonsillectomy (eg, history of frequently recurrent tonsillitis or obstructive sleep apnea). Otherwise, if patients have also had recurrent tonsillitis, elective tonsillectomy is performed 4 to 6 weeks later to prevent abscess recurrence.