Peritonsillar Abscess

Clinical suspicion

Swollen/red peritonsillar region causing uvular shift

Fluctuance of area

Interim treatment for peritonsillar closed space infection until tonsillectomy

CONTRAINDICATIONS

Extension into the deep neck tissue

Septicemia/toxic appearance

Airway obstruction

Severe trismus

Coagulopathy

General Basic Steps

Patient preparation

Analgesia

Visualization

Needle aspiration/incision and drainage (I&D)

LANDMARKS

Superior lateral border of affected tonsil, or area of most fluctuance

Aspirate peritonsillar abscess’ (PTA’s) superior pole first, then middle pole, and finally the inferior pole (FIGURE 76.1)

TECHNIQUE

Patient Preparation

Cooperative patient sitting upright in a chair with occipital support

Consider intravenous analgesia or sedation

Digital exam key: Must feel abscess!

Use ultrasound (endocavitary probe) to assess volume, location, and relationship to the carotid artery (FIGURE 76.2)

Needle Aspiration

Anesthetize with benzocaine spray or have patient gargle viscous lidocaine

Have patient depress own tongue by holding laryngoscope, insert as you would for intubation. Patient will be less likely to trigger own gag reflex while pulling down on blade (FIGURE 76.3)

Anesthetize locally with 1 to 2 mL of 1% lidocaine via 27-gauge needle

Use a long spinal needle so visualization is not obscured by syringe

Cut the distal 1 cm off of the needle cover and recap the needle, thereby preventing the needle from penetrating >1 cm (FIGURE 76.4)

Insert spinal needle at area of greatest fluctuance (usually the superior pole) and aspirate the pus

FIGURE 76.1 A: Peritonsillar abscess. The tonsil is displaced forward and inferomedial, the uvula is deviated toward the unaffected tonsil, and the soft palate is edematous and ruborous. B: Recommended sites for three-point needle aspiration of a peritonsillar abscess. (From Saladino RA. Pharyngeal procedures. In: Henretig FM, King C, eds. Textbook of Pediatric Emergency Procedures. Philadelphia, PA: Williams & Wilkins; 1997:692, 696, with permission.)

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