Peri-Tonsillar Abscess Evaluation and Treatment
The tonsils are located in the back of the mouth flanking the uvula (the little dangling thing at the back) along the sides of the throat. The tonsils are basically lymph nodes just like in your neck, but rather than being hidden under the skin, they are on the surface of your throat where you can see them. As such, removal of the tonsils and adenoids have minimal (if any), impact on a patient's immune system as there are hundreds of other lymph nodes that can pick up the slack.
Not uncommonly, the tonsils can get infected resulting in tonsillitis where they become enlarged and inflamed causing symptoms of sore throat, pain with swallowing, and overall feeling lousy.
Unfortunately, not only can the tonsils get infected, but they also can develop an abscess. And just like any other abscess in other parts of the body, treatment is incision and drainage. For example, cellulitis is a skin infection which requires only antibiotics. A skin boil is an abscess that requires incision and drainage.
Diagnosing a Peritonsillar Abscess
A patient who develops a peritonsillar abcess often complains of a severe sore throat on ONE side in particular and trouble swallowing... even more so than with a simple tonsillitis. The pain may be so severe, many patients may have trouble eating or drinking. Drooling can even occur. The symptoms can occur quite suddenly from a minor sore throat to raging abscess within a 24 hour period of time.
A peritonsillar abscess can be diagnosed on exam:
- A large tonsil on one side that often crosses the midline
- Uvula pushed to the opposite side of the mouth
- Soft palate bulging on same side of enlarged tonsil
- Neck quite tender and sore on same side of enlarged tonsil
- Fever may be present, though not always
Treatment of Peritonsillar Abscess
Our opinion is that treatment of a peritonsillar abscess is best accomplished by surgical incision and drainage! There are many ways this procedure is performed, but below outlines at least one way of doing it. Also, depending on the clinical scenario, rather than an incision, a needle aspiration may be performed though often the pus re-accumulates and will need to be followed up with definitive incision and drainage within a day or two.
This is what the back of the mouth SHOULD look like.
In this picture, the patient has a left peritonsillar abscess. Anesthesia is applied to the left tonsil region both topically as well as by injection.
After adequate anesthesia, a scalpel is used to create a ~2cm incision along the bottom border of the soft palate as shown by the red line.
With incision, pus is expressed and suctioned out. Often, a clamp needs to be inserted into the incision in order to open the pus pocket up to allow pus flow.
After incision and drainage has been performed, the patient is usually allowed to go home with antibiotics. A single dose of steroids may be given.
If the patient is severely dehydrated, they may be admitted for IV fluids for hydration as well as IV antibiotics. Normally, patients who are admitted usually are able to go home the next day.
If a patient has had recurrent tonsillitis and/or prior episodes of peritonsillar abscesses in the past, tonsillectomy should probably be considered, but once things are back to normal.
Tonsillectomy performed in a state of active infection have a higher risk of bleeding as well as more bleeding during surgery due to the exuberant inflammatory response.
What About Kids?
In kids, general anesthesia may be required as the child may not be cooperative enough to perform this procedure awake. Also, if the peritonsillar abscess is large enough, airway may be of concern requiring prolonged intubation after incision and drainage. Intubation may even be a challenge for which tracheostomy may be required for airway control prior to incision and drainage. What actually happens depends on the age, how cooperative the child is, and how large the abscess is.
If you are concerned for a peritonsillar abscess, contact our office for an appointment! OR... go to the emergency room!
DID YOU KNOW that a person has a total of FOUR tonsils... one adenoid, two tonsils, and one lingual tonsil. The lingual tonsil is located on the back of the tongue. When lingual tonsils start to cause problems, they also can be removed.
If your tonsils and/or adenoids are affecting your quality of life, please contact our office for an appointment.
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