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ACUTE TONSILLITIS

Overview
Acute tonsillitis generally does not require surgical management; however, an understanding of this diagnosis is necessary to differentiate it from peritonsillar cellulitis and abscess, which more frequently require Otolaryngology evaluation and treatment. The key differentiating feature of acute tonsillitis from a peritonsillar process is bilateral and symmetric tonsillar enlargement with uninvolved adjacent structures. In peritonsillar pathology, the soft palate is frequently asymmetrically enlarged or edematous. The majority of patients with acute tonsillitis, without airway or dehydration concerns, can be managed as outpatients. Treatment generally consists of a 10-day course of penicillin, amoxicillin-clavulanic acid, or clindamycin in the case of penicillin allergy or suspicion for mononucleosis. Patients with pain resulting in poor oral intake may benefit from a 1-2 day course of steroids and liquid pain medication. For guidelines on Tonsillectomy indications, we recommend review of the Tonsillectomy in Children CPG by the AAO-HNS.

Severe Acute Tonsillitis 
Uncommonly, patients may present with dehydration or airway compromise secondary to significantly enlarged tonsils. In younger children, severe acute tonsillitis sometimes requires admission for intravenous hydration, oral or intravenous pain medication, intravenous steroids (e.g., dexamethasone), or intravenous antibiotics (e.g., ampicillin-sulbactam, or clindamycin if mononucleosis is suspected). If there is suspicion for mononucleosis, recall that Monospot testing may result in a false negative result in the first several weeks and in the case of high clinical suspicion, diagnosis may require peripheral smear (looking for >50% mononuclear cells and atypical lymphocytes) or viral titers. 

When appropriate, patients may be discharged with oral antibiotics (e.g., amoxicillin-clavulanic acid for 10 days) and oral pain medication. Patients should have close follow up scheduled with a primary care provider within two weeks and the indications to seek earlier medical attention should be clearly communicated.

Peritonsillar Phlegmon and Abscess

Overview
In contrast to acute tonsillitis, patients with peritonsillar phlegmon or abscess typically present with soft palate edema, erythema, trismus, and otalgia. A distinguishing feature of peritonsillar phlegmon or abscess on physical examination is the inferior medial displacement of the infected tonsil with a contralateral deviation of the uvula. Patients generally appear sick and frequently have a muffled “hot potato” voice, trismus, cervical lymphadenopathy, and sometimes difficulty swallowing secretions.

Peritonsillar cellulitis/phlegmon and PTA can appear similar on physical examination. Peritonsillar phlegmon represents an early stage of infection in which a well-circumscribed abscess has not formed. In some cases of PTA, a fluctuant mass can be palpated along the soft palate. In most cases, CT findings can guide treatment, and can differentiate between tonsillar abscess, peritonsillar phlegmon, PTA or other deep neck space infections. Although polymicrobial infections are common, Streptococcus pyogenesis the most frequently isolated microbe in PTA.

Cannot Miss Diagnoses

  • Airway compromise

  • Retropharyngeal (or other deep neck space) abscess

  • Tonsillar / Oropharyngeal Malignancy

Key Supplies for Peritonsillar Abscess Drainage

  • Headlight

  • Tongue depressor or retractor

  • Kidney basin

  • Suction with Yankauer tip

  • Flexible laryngoscopy scope 

  • Benzocaine or cetacaine spray 

  • 1% lidocaine with 1:100,000 epinephrine 

  • 18-gauge needle 

  • 27-gauge needle

  • 12 mL Luer lock syringe 

  • Curved Kelly forceps 

  • 15-blade or 11-blade 

  • Culture swab

  • Cup of ice water for patient

Management
In general, it is agreed upon that peritonsillar phlegmon, PTA, and tonsillar abscesses should be treated with antibiotics. The need for and type of procedural intervention, however, varies across practices. In general, abscesses are drained with either needle aspiration or incision and drainage at bedside, especially when larger than 1.5-2cm. In loculated abscesses, a true incision and drainage to break up the loculations may be more useful compared to a needle aspiration. With smaller abscesses, it may be reasonable to either drain or complete a trial of antibiotics first. Guidelines for patient evaluation and management are listed below:

  • Perform a complete head and neck physical exam. If there is any concern of airway compromise or obstruction, flexible transnasal laryngoscopy is recommended. Airway obstruction or concerns require admission for observation and treatment

  • Labs: CBC with differential, rapid streptococcus test, Monospot test in young adults

  • Imaging: In cases where the location of the abscess is apparent from examination, imaging may not be required prior to drainage. Otherwise, a CT neck with contrast is recommended for targeted drainage

  • Consider treating with oral analgesics, intravenous fluids, intravenous dexamethasone and either intravenous ampicillin/sulbactam or clindamycin

  • After draining the abscess, patients should be discharged on amoxicillin/clavulanate, clindamycin, or an appropriate alternative for 10-14 days. If cultures are sent, antibiotics should be tailored accordingly

  • Can also consider discharging with Medrol Dosepak if significant swelling is present and oral saline/chlorhexidine rinses four times daily after incision and drainage

  • In rare cases of severe airway obstruction or failed incision and drainage, a Quincy tonsillectomy (at time of infection) may be considered

Follow-up

  • Follow up is recommended for all patients to confirm resolution of abscess or infection

  • In cases of first-time PTA in children or adolescents (without other concerning history such as OSA, recurrent PTAs or recurrent tonsillitis), follow-up with a pediatrician is reasonable

  • In adults, it is important to perform an exam of the tonsils after the infection has cleared to rule out malignancy as an underlying cause; follow-up with Otolaryngology is recommended

  • In patients with recurrent PTA, follow up with Otolaryngology may be useful for consideration of tonsillectomy

Procedural Steps for Peritonsillar Abscess Drainage

  • Obtain written consent from patient noting that there is a 5-20% recurrence rate despite drainage

  • Review CT scan for location of abscess relative to surrounding anatomy, and for location of vessels such as carotid artery

  • Position patient sitting upright with gown on, holding kidney basin and water to rinse mouth

  • Ready equipment – ensure good lighting, suction on with Yankauer tip in place 

  • Spray peritonsillar with Hurricane spray or another appropriate alternative

  • Optional: palatine nerve block (injection medial to third maxillary molar) using 1% lidocaine with epinephrine 1:100,000; inject (using 27-gauge needle) in the superior pole of the tonsil and supratonsillar fossa 

  • Aspirate abscess using 18-gauge needle and 12 mL syringe 

  • If no significant purulence is aspirated after three attempts, some providers will stop, others will proceed to open the peritonsillar space 

  • To open, make a 1-2cm incision through the mucosa parallel to the anterior tonsillar pillar using 15-blade; spread open the incision using the Kelly clamp and have suction ready

  • The open cavity can be flushed with saline and/or directly suctioned 

Example Procedural Note 
The posterior oropharynx was anesthetized with ___ spray followed by ___ cc of ___% lidocaine with ___ epinephrine. An ___-gauge spinal needle with a syringe was then inserted across the superior and lateral aspect of the [right, left] tonsil. Aspiration produced approximately ___ cc of purulent material, which was sent for cultures. A No.___ blade was then used to sharply incise the abscess cavity, which was spread widely open using curved Kelly forceps. The patient tolerated the procedure well, and the surgical site was hemostatic at the end of the procedure.

I expressed to the patient that a combination of antibiotics and open drainage will hopefully lead to their convalescence in 3-5 days' time. If the patient does not feel better or experiences worsening of symptoms, they are advised to return. I stressed the importance of adhering to the prescribed antibiotic course. The patient expressed understanding and agreement with the plan. 

 

References

  1. Christian, J.M., et al (2020). Deep Neck and Odontogenic Infections. In P.W. Flint, et al (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 141-154). Philadelphia, PA: Elsevier.

  2. Jeyakumar, A., et al. (2013). Adenotonsillar Disease in Children. In J.J. Johnson, C.A. Rosen. (Eds.), Bailey’s Head and Neck Surgery-Otolaryngology 5e (pp. 1430-1444). Baltimore, MD: Lippincott Williams & Wilkins.

  3. Mitchell, R. B., Archer, S. M., Ishman, S. L., Rosenfeld, R. M., Coles, S., Finestone, S. A., … Nnacheta, L. C. (2019). Clinical Practice Guideline: Tonsillectomy in Children (Update). Otolaryngology–Head and Neck Surgery, 160(1_suppl), S1–S42.https://doi.org/10.1177/0194599818801757