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Peritonsillar Abscess and Cellulitis

by Clarence T. Sasaki, MD

Peritonsillar abscess and cellulitis are acute pharyngeal infections most common among adolescents and young adults. Symptoms are severe sore throat, trismus, "hot potato" voice, and uvular deviation. Diagnosis requires needle aspiration. Treatment includes broad-spectrum antibiotics, drainage of any pus, hydration, analgesics, and, occasionally, acute tonsillectomy.

Etiology

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. Streptococcusand Staphylococcus are the most frequent aerobic pathogens, whereas Bacteroides sp is the predominant anaerobic pathogen.

Symptoms and Signs

Symptoms include gradual onset of severe unilateral sore throat, dysphagia, fever, otalgia, and asymmetric cervical adenopathy. Trismus, "hot potato" voice (speaking as if a hot object was in the mouth), a toxic appearance (see Epiglottitis), drooling, severe halitosis, tonsillar erythema, and exudates are common. Abscess and cellulitis both have swelling above the affected tonsil, but with abscess there is more of a discrete bulge, with deviation of the soft palate and uvula and pronounced trismus.

Diagnosis

  • Needle aspiration

  • Sometimes CT

Peritonsillar cellulitis is recognized in patients with severe sore throat who have trismus, "hot potato" voice, and uvular deviation. All such patients require needle aspiration of the tonsillar mass and cultures. Aspiration of pus differentiates abscess from cellulitis.

CT or ultrasonography 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.

Treatment

  • Antibiotics

  • Drainage of abscess

Cellulitis subsides, usually within 48 h, with hydration and high-dose penicillin (eg, 2 million units IV q 4 h or 1 g po qid); alternative drugs include a 1st-generation cephalosporin or clindamycin. Culture-directed antibiotics are then prescribed for 10 days.

Abscesses are incised and drained in the emergency department using thorough local anesthesia and sometimes procedural sedation; many clinicians believe needle aspiration alone provides adequate drainage. 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 done, 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, elective tonsillectomy is done 4 to 6 wk later to prevent abscess recurrence.

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