Peritonsillar abscess (PTA) is a relatively commonly encountered diagnosis in the ED. Generally, these patients present with complaints of pain with swallowing, unilateral sore throat, fevers, and muffled “hot potato” voice. Trismus is very common, with 2/3 of patients experiencing limited jaw opening. If the patient has neck stiffness, pain with flexion/extension of the neck, anxious appearance, is leaning forward, drooling, stridor, and/or looks toxic, there may be a deeper infection present. If this is a concern, CT with contrast of the neck is a good idea (but is probably not necessary in all relatively benign appearing patients with evidence of a PTA). Exam will show a medially displaced swollen/erythematous tonsil with deviation of the uvula away from the abscess.

PTA drainage is similar to other I&D in the sense that it is a pocket of pus that needs to be opened. It just happens to be in a somewhat anxiety producing area with large, important structures required for life like the airway and the big ol’ carotid. While landmarks are important to avoid important structures, the use of US can also be helpful to locate the abscess and the other scary things that you don;t want to poke.

Things to Consider:

Patient cooperation is absolutely key with this procedure – you do not want to try to put a sharp object in the back of someone’s throat if they are going to thrash around. Anxiolytics can help but be careful to avoid excessively sedating when doing airway adjacent procedures.
Nonverbal communication is also important – because you will be working in the patient’s mouth, they will not be able to speak to tell you if they need something or if they want you to stop. Rather than force the patient to move around to get your attention, figure out a signal prior to starting the procedure – e.g. the patient lifts their right hand to signal you.
Using a laryngoscope or speculum can help act as a tongue depressor while also providing light.
Lemierre’s syndrome is a rare complication of pharyngitis/PTA – the infection causes a septic thrombophlebitis of the jugular vein with resultant septic emboli. Consider this in patients who look sick and/or are persistently tachycardia.

Consent:

Risks: pain, bleeding, worsening infection, damage to surrounding structures including carotid artery, airway obstruction, hypoxia, failure of procedure or need for operation
Alternatives: antibiotics (this may be appropriate in some smaller PTA but does carry higher risk of recurrence), drainage in the OR, tonsillectomy
Contraindications: unclear diagnosis or concern for deeper infection, coagulopathy, severe trismus, inability to visualize anatomic structures, uncooperative patient

Relative contraindications: immunocompromise/diabetes or signs of sepsis where more extensive operative management may be indicated

Supplies:

Syringe/needle for injecting - 5-10 ml syringe with 27 ga needle
Lidocaine

Plain 1-2% lidocaine if nebulizing
1% Lidocaine with epi if injecting
4% Viscous lidocaine if gargling

18 ga needle with guard/cover

Can use an 18 ga spinal needle

5 ml syringe – using a larger one may make it harder to aspirate

Dental/aspirating syringe with loops may be helpful

11 blade scalpel
Tape
Scissors/trauma shears
Yankauer suction with tubing setup
Video/direct laryngoscope with Mac blade or lighted speculum (the disposable ones used for pelvic exams)
A cot/stretcher/chair where the patient can sit up with the head stabilized

How to do it:

Identify the area to drain.

This can be done using anatomic landmarks

Using ultrasound with the endocavitary probe

Key tip – do not refer to it as the vaginal probe to patients
Abscess should appear as a hypoechoic region
Can estimate abscess depth and use color doppler to identify the carotid

Using ultrasound with linear probe via submental approach

Once the presence of the abscess and ideal drainage location are confirmed, anesthetize the patient

Nebulize a few ml of lidocaine over 5 min OR have patient gargle lidocaine 4%
Inject lidocaine with epi directly into PTA after neb/gargle

Set up your equipment

Attach the 18 ga needle to the 5 ml syringe
Remove the cover guard and cut approximately 1 cm the tip off the plastic guard, then replace on the needle – this will make it so the needle cannot penetrate more than 1 cm into the tissue, which can protect the carotid and deeper structures from inadvertent puncture

If using a scalpel, retract the cover 1 cm and then tape to secure.

Set up your light source

If using a speculum, remove the top half

The laryngoscope should be held with the handle down – a video scope may help visualize posterior pharyngeal structures better, but a direct laryngoscope could also be used.

Set up suction – patient can hold Yankauer to suction saliva during the procedure and drainage from the abscess once opened
Position patient sitting up with head against the back of the chair/cot – you do not want patient to be moving their head around or laying flat and choking on secretions
After ensuring you have a way for your patient to signal discomfort, have the patient open their mouth and insert the speculum or laryngoscope. Position the light source yourself initially but then have the patient hold in place.

Having patient hold the speculum/laryngoscope may help with some gagging/discomfort.

Slowly advance 18 ga needle with trimmed cap guard until tip is near the superior pole of the PTA

Run the needle over the speculum/laryngoscope – can use the blade to steady the syringe as you advance

Apply back pressure to the syringe plunger as the needle is inserted into the superior pole

If no purulence/drainage, can move slightly inferiorly to the middle pole, and then to the inferior pole if still unsuccessful
This may take a few passes!

If limited drainage after attempting with a needle in multiple locations, try using the taped 11 blade scalpel to make a stab incision at the superior pole of the abscess
Have suction ready to help clear the purulence

Can have patient swish and spit using ice water to help with pain and to clear secretions

Once drained, observe patient in the ED for a short time to ensure no complications

Post Procedure Care:

Send drainage for culture – this will be useful if the patient has re-accumulation
Antibiotics coverage should include group A strep, staph aureus, and respiratory anaerobes

Augmentin vs clindamycin
Unasyn, Zosyn, clindamycin if IV indicated

Steroids may help improve swelling/pain faster (but evidence is a little mixed)

Single dose of methylprednisone 125 mg IV or dexamethasone 10 mg PO/IM/IV

Refer to ENT – patient should be seen in 24-48 hours after drainage to ensure improvement

References:

Videos:

https://www.youtube.com/watch?v=gnO7QaxkWno – a little longer video but shows multiple techniques and the use of saline irrigation
https://www.youtube.com/watch?v=9fd8qFAptM4 – good step-by-step using direct laryngoscope. Has a creepy mannequin
https://www.youtube.com/watch?v=MnxDkOpSDZA – discusses the US techniques to localize abscess and shows drainage with some tips for success
https://www.tamingthesru.com/blog/ultrasound/us-of-the-month/pta - good discussion of US approaches with some short videos
https://www.youtube.com/watch?v=1CJgLTd35wo
https://www.youtube.com/watch?v=ZGIQZUXz36I – uses a simple tongue depressor