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Slide 1 - Approach to Sore Throat & Peritonsillar Abscess MR 8/3/09 J.Chen
Slide 2 - General Approach R/O Life Threatening causes R/O non-infectious causes Determine whether or not treatment is required
Slide 3 - Life Threatening Causes Airway Compromise Sitting in sniffing position Toxic appearing Drooling Voice change Fever
Slide 4 - Life Threatening Causes Epiglottitis Retropharyngeal abscess Peritonsillar abscess Significant tonsillar hypertrophy Diphtheria
Slide 5 - Management NPO Supplemental O2 Consider airway adjunct (NP airway) IV access (if pt can tolerate) Anesthesia
Slide 6 - Non-infectious Causes Environmental Irritative pharyngitis Smoke Dry air Chemicals Trauma Burns Foreign Body Retained Laceration to posterior pharynx
Slide 7 - Non-infectious Causes Allergic/Inflammatory Allergens causing chronic postnasal drip Eosinophilic esophagitis Tumors Rare in pediatric population
Slide 8 - Infectious Causes Bacterial: Group A Beta Hemolytic Streptococcus Group C Strep Group G Strep Neisseria Gonorrhoeae Tularemia Chlamydia Mycoplasma Diptheria
Slide 9 - Infectious Causes Viral Causes Adenovirus Influenza Parainfluenza Epstein-Barr Virus Cytomegalovirus HIV Stomatitis HSV Coxsackievirus
Slide 10 - History Drooling? Voice Change? Fever? Exposure? Foreign Body? Headache? Abdominal Pain? URI symptoms? Immunization status? Sexual activity?
Slide 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
Slide 12 - Laboratory Aids Throat Culture Lateral Neck X-ray CBC Monospot
Slide 13 - Peritonsillar Abscess Suppurative infection of the tissues adjacent to the palatine tonsil Most common abscess of the head and neck
Slide 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)
Slide 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
Slide 16 - History Sore Throat/Dysphagia 5-7 days Trismus (2nd to inflammation of internal pterygoid muscle) Fever Drooling Muffled Voice Referred Ear Pain
Slide 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
Slide 18 - Physical Exam Moderately uncomfortable appearing Febrile Potential resp distress Trismus Halitosis Cervical adenopathy
Slide 19 - Laboratory Tests CBC with diff-leukocytosis with neutrophil predominance Needle aspiration for culture and sensativity
Slide 20 - 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
Slide 21 - Complications Airway Compromise Aspiration of abscess contents Parapharyngeal abscess Sepsis Hemorrhage Contiguous spread to pterygomaxillary space
Slide 22 - Treatment Hydration Analgesia Antibiotics Admit patients for: Airway Compromise Dehydration, inability to take PO Poor Compliance Systemic complication Toxic Appearing Unclear diagnosis
Slide 23 - Antibiotics Augmentin (amox+clavulanate) is DOC Unasyn (amp+sulbactan) for inpatient Ceftriaxone and clindamycin or imipenem for severe or complicated cases
Slide 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
Slide 25 - I&D Wider Drainage More Painful Containdications: same as needle aspiration Tonsillectomy Definitive Therapy May decrease overall duration of stay Requires OR and intubation