Paediatric Acute care Guidelines PMH Emergency Department

A peritonsillar abscess (also called paratonsillar abscess) is a collection of pus in the space between the tonsil and the superior pharyngeal constrictor muscle.

Background

A peritonsillar abscess is often considered to be a complication of tonsillitis. However, it is now thought to be secondary to infection of a peritonsillar salivary gland (Weber gland) which is located between the tonsillar capsule and the muscle of the tonsillar fossa.

Assessment

Patients often present with:

  • Severe sore throat
  • Odynophagia (painful swallowing) with drooling
  • Muffled voice ( ‘Hot Potato Voice’)
  • Difficulty opening mouth (trismus)

Examination often reveals:

  • Limited mouth opening (trismus), less than three finger width
  • Unilateral swollen enlarged tonsil with fluctuant swelling extending up to the soft palate (most characteristic)
  • Deviation of the uvula away from the affected side
  • Enlarged tender cervical lymph node on the associated side
  • The patient is usually febrile, and often ‘toxic’ looking 

Management

  • Patients require hospitalisation for rehydration, intravenous antibiotics, analgesia and, in most cases, surgical drainage of the abscess.
  • Antibiotics need to cover Streptococcus pyogenes and anaerobes
    • A combination of intravenous Benzylpenicillin and Metronidazole is recommended – Antibiotics
  • As a rule of thumb, all peritonsillar abscesses should be drained
    • Generally, children less than 7-10 years of age will not tolerate oropharyngeal procedures under local anaesthetic very well. Needle aspiration or incision and drainage of the abscess under general anaesthesia is usually required.
    • Patients who are septic and have airway obstruction may be considered for quinsy tonsillectomy.

It is worth noting that in some very young children quinsy tends to resolve with IV antibiotics, hence medical treatment and observation for 24 hours may be worthwhile. 

Nursing

  • Baseline observations: heart rate, respiratory rate, temperature, SpO2, blood pressure and pain score
  • Minimum of hourly observations should be recorded whilst in the Emergency Department 
  • Fluid input/output is to be monitored and documented

References

  1. Wald ER (2014) Peritonsillar Cellulitis and Abscess. UpToDate. Accessed at www.uptodate.com
  2. WA Health Child and Adolescent Health Service. Ear, Nose, Throat and Dental ChAMP Empiric Guidelines Version 2, February 2014

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