Case Study of the Week: Peritonsillar Abscess

A sore throat seems easy enough to treat.  You order a strep test, decide if the patient will require antibiotics and recommend over-the-counter analgesia.  But,  there's more to diagnosing and treating pharyngitis than simply determining if a particular case warrants antibiotics or is likely viral.  Sometimes a sore throat is caused by more than a simple case of strep.

Each tonsil is surrounded by a capsule providing a pathway for nerves and blood vessels.  A peritonsillar abscess is a collection of pus that forms in the space between the tonsil and the capsule.  Nurse practitioners must be aware of how to diagnose and treat a peritonsillar abscess as it can present some serious complications.  

Case Presentation

A 28 year old male presents to your emergency department complaining of a sore throat worse on the left side, swollen glands, low grade fever, neck pain, bodyaches, and a change in voice.  He has been ill for three days and his symptoms have been progressively worsening.  He denies difficulty breathing but states he has difficulty swallowing.

The patient reports no significant medical history and does not take any medications. His vital signs are as follows: BP 132/86, HR 114, RR 18, T 100.8.  On exam, you note the patient's voice is thick and muffled having a "hot potato" quality.  The patient's lungs are clear.  His nose and tympanic membranes appear normal.  You note cervical lymphadenopathy on the left side of his neck.  The patient has notable trismus (difficulty or inability to open the mouth).  On examining his pharynx, you note the patient's left tonsil is swollen and his uvula deviates to the right side away from the swelling.  Tonsillar exudate is present.  

Based on this patient's presentation and exam, you suspect a diagnosis of peritonsillar abscess and order imaging studies to confirm your diagnosis.

Management and Outcome

Imaging studies are used to confirm a diagnosis of peritonsillar abscess (PTA) and assess the size of the abscess.  Intraoral ultrasound is a cost-effective method for evaluating PTA.  However, some patients, especially those with trismus, may have difficulty with the procedure.  A CT scan of the neck with IV contrast can also confirm a diagnosis of PTA and provide an assessment of the abscess.  

If a peritonsillar abscess is large, it can threaten the patient's airway.  Make sure to pay attention to the patient's ABC's.  These are your first priority.  If you suspect airway compromise, consult a physician immediately as the patient may require intubation.  Pain medication and antipyretics for fever should be given as needed.  Consider ordering IV fluids as patients with PTA may be dehydrated as a result of fever and decreased oral intake.  

The gold standard for treatment of PTA is needle aspiration.  Most often, this is done by an ear, nose and throat physician.  To aspirate the abscess, the area is numbed with Cetacaine spray.  Then, a needle attached to a syringe is used to puncture the abscess and pull out the purulent fluid.  The contents of the abscess should be sent for culture to help guide antibiotic therapy.  This procedure must be performed by an experienced physician as the carotid artery lies near the tonsils.  Puncture of the carotid artery results in serious complications. 

IV penicillin is the antibiotic of choice for treating PTA.  However, given increasing penicillin resistance, IV clindamycin may also be considered.  Some studies also recommend adding metronidazole to the treatment regimen if the patient has not improved within the first 24 hours. 

Patients with uncomplicated or minor PTA may be treated on an outpatient basis while patients with more severe symptoms require inpatient management. 

Discussion

Nurse practitioners must be familiar with the presentation of peritonsillar abscess and not misdiagnose the condition as simple tonsillitis.  Given it's potential for airway compromise, PTA must be diagnosed and treated promptly.  

 

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