Approach to Sore Throat

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Approach to Sore Throat Peritonsillar Abscess

• MR 8/3/09
• J.Chen

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General Approach

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

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Life Threatening Causes

• Airway Compromise
• Sitting in sniffing position
• Toxic appearing
• Drooling
• Voice change
• Fever

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Life Threatening Causes

• Epiglottitis
• Retropharyngeal abscess
• Peritonsillar abscess
• Significant tonsillar hypertrophy
• Diphtheria

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Management

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

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Non-infectious Causes

• Environmental
• Irritative pharyngitis
• Smoke
• Dry air
• Chemicals
• Trauma
• Burns
• Foreign Body
• Retained
• Laceration to posterior pharynx

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Non-infectious Causes

• Allergic/Inflammatory
• Allergens causing chronic postnasal drip
• Eosinophilic esophagitis
• Tumors
• Rare in pediatric population

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Infectious Causes

• Bacterial
• Group A Beta Hemolytic Streptococcus
• Group C Strep
• Group G Strep
• Neisseria Gonorrhoeae
• Tularemia
• Chlamydia
• Mycoplasma
• Diptheria

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Infectious Causes

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

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History

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

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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

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Laboratory Aids

• Throat Culture
• Lateral Neck X-ray
• CBC
• Monospot

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Peritonsillar Abscess

• Suppurative infection of the tissues adjacent to
  the palatine tonsil
• Most common abscess of the head and neck

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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)

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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

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History

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

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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

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Physical Exam

• Moderately uncomfortable appearing
• Febrile
• Potential resp distress
• Trismus
• Halitosis
• Cervical adenopathy

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Laboratory Tests

• CBC with diff-leukocytosis with neutrophil
  predominance
• Needle aspiration for culture and sensativity

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Imaging

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

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Complications

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

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Treatment

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

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Antibiotics

• Augmentin (amoxclavulanate) is DOC
• Unasyn (ampsulbactan) for inpatient
• Ceftriaxone and clindamycin or imipenem for
  severe or complicated cases

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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

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• ID
• Wider Drainage
• More Painful
• Containdications same as needle aspiration
• Tonsillectomy
• Definitive Therapy
• May decrease overall duration of stay
• Requires OR and intubation