A 25 year old male walks into your fast track complaining of a sore throat. You note significant peritonsillar swelling and uvular deviation to the contralateral side. You suspect peritonsillar abscess, a diagnosis which is most often made by your history and physical alone. If you want to get ultrasound involved, use the intracavitary probe and bring your sensitivity up to 89-95% and specificity to 79-100%. Either way, you decide it’s time to drain this puppy. And you are not calling ENT…until your attending says so.
[spacer height=”20px”]Anatomy:
[spacer height=”20px”]Of importance is the fact that a peritonsillar abscess is not within the tonsil itself, but rather, as the name indicates, is located between the tonsillar capsule, superior constrictor muscle, and palatopharyngeus muscle
. The abscess most commonly arises from the superior pole of the tonsil. Thus your needle insertion point will be along the soft palate, medial to the tonsil, superior and lateral to the uvula, between the uvula and maxillary alveolar ridge. The most important structure to avoid while draining a PTA is the internal carotid artery which is located approximately 2.5cm postero-lateral to the tonsil. This means minimal room for error and as such, an uncooperative patient or one with severe trismus is not a good candidate for drainage.
. The abscess most commonly arises from the superior pole of the tonsil. Thus your needle insertion point will be along the soft palate, medial to the tonsil, superior and lateral to the uvula, between the uvula and maxillary alveolar ridge. The most important structure to avoid while draining a PTA is the internal carotid artery which is located approximately 2.5cm postero-lateral to the tonsil. This means minimal room for error and as such, an uncooperative patient or one with severe trismus is not a good candidate for drainage. [spacer height=”20px”]Equipment:
[spacer height=”20px”]-analgesic spray – lidocaine or cetacaine
-viscous lidocaine “lollipop” (4×4 soaked in viscous lido, taped around a tongue depressor) OR 1-2cc lido/epi drawn up in a syringe for injection with 25 gauge needle
-18 gauge needle attached to 10cc syringe, with plastic cover in place with distal 1cm cut off, or tape, so that needle is reduced to a length of 1cm
-scalpel with 11-blade, with plastic tape limiting blade length to 0.5-1cm
-kelly clamp
-tongue depressor
-suction
[spacer height=”20px”]Procedure:
[spacer height=”20px”]1. Analgesia: spray and lido pop vs injection as seems fit for the patient
2. Place tongue depressor or gloved finger into the mouth to remove the tongue from blocking your site
3. Insert 18 gauge needle tip, no deeper than 1cm, into superior site along the soft palate, medial to tonsil, aiming straight on or medially, NOT LATERALLY, pulling back on the syringe as you go
4. Expect about 2-6 ml of drainage
4. Suction as needed
[spacer height=”20px”]Other options/tips:
[spacer height=”20px”]1. If you’re having trouble visualizing your site, try using a laryngoscope instead of a tongue depressor – it has a nice big blade and a light!
2. If you do not draw back any pus, you may progress from the superior needle insertion site to the middle to the inferior as seen in the above image.
3 . If still no drainage, with a definite abscess/fluctuance visualized, consider moving on to the scalpel technique: incise to approximately 0.5-1cm depth and use suction throughout. Use a kelly clamp to break up loculations. Caution, this will get bloody. Have the patient gargle with a saline rinse. Observe for bleeding/airway compromise for at least 1 hour.
[spacer height=”20px”]Conclusion:
High-five your coresidents and discharge on augmentin or clinda with follow up in 24 hours!
[spacer height=”20px”]Video:
[spacer height=”20px”]Further Resources:
http://accessemergencymedicine.mhmedical.com/content.aspx?sectionid=109387281&bookid=1658&jumpsectionID=109387300&Resultclick=2&q=peritonsillar%20abscess
https://www.clinicalkey.com/#!/content/book/3-s2.0-B978145570606800063X?scrollTo=%23hl0000377
