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What is a peritonsillar abscess and where is it located?
A peritonsillar abscess is a collection of pus located between the fibrous capsule of the tonsil and the superior constrictor muscles of the pharynx.
Identify the primary age group affected by peritonsillar abscesses.
The majority of cases occur in young adults between 20 and 39 years of age.
List two types of bacteria commonly associated with peritonsillar abscess.
Anaerobic organisms and beta haemolytic streptococcal infections.
What clinical feature is considered virtually pathognomonic for a peritonsillar abscess?
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Describe one differential diagnosis for peritonsillar abscess.
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What imaging technique may be used for suspected vascular anomalies in cases of peritonsillar abscess?
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What is the initial treatment approach for managing a peritonsillar abscess?
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What are two methods of drainage for a peritonsillar abscess?
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What imaging technique is primarily used to demonstrate foreign body penetration in the neck?
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In the management of retropharyngeal abscess, what is the standard initial treatment?
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What notable complication may arise from retropharyngeal abscess, particularly involving cervical necrotizing fasciitis?
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Identify the most common bacteriological agent responsible for retropharyngeal abscess.
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What clinical features are often seen in young children diagnosed with a retropharyngeal abscess?
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For adults with a retropharyngeal abscess, why is it important to obtain a history of previous tuberculosis contact?
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What is the traditional site for drainage of a retropharyngeal abscess?
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What is the peak incidence age range for retropharyngeal abscess in children?
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What is a common recommendation after recurrent quinsy, and what is the typical waiting period before this procedure?
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What is the significant mortality rate associated with mediastinitis?
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Which bacterial organisms are commonly associated with parapharyngeal abscess?
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Identify two primary compartments of the parapharyngeal space.
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What distinguishes parapharyngeal abscess from peritonsillar abscess in terms of clinical features?
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What anatomical structures bound the parapharyngeal space laterally?
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What are some rare causes of parapharyngeal abscess aside from tonsillitis?
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What key anatomical feature communicates the parapharyngeal space with the retropharyngeal space?
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Study Notes
Peritonsillar space
- The peritonsillar space is located between the capsule of the palatine tonsil and the superior pharyngeal constrictor muscle.
- It is bounded by the anterior and posterior tonsil pillars superiorly and inferiorly, respectively.
Peritonsillar abscess
- Peritonsillar abscess (PTA), also known as Quinsy, is a collection of pus in the peritonsillar space, usually at the upper pole.
- It typically arises as a complication of tonsillitis.
- PTA is most common in young adults between 20 and 39 years of age.
Bacteriology of PTA
- Anaerobic organisms are commonly involved in PTA.
- Beta-hemolytic streptococcal infection is a frequent cause.
- Methicillin-resistant Staphylococcus aureus (MRSA) has been identified in cases of PTA.
Clinical features of PTA
- Progressive, usually unilateral, sore throat that develops over 3-4 days.
- Odynophagia (painful swallowing).
- Dysphagia (difficulty swallowing) for solids and eventually liquids.
- Drooling of saliva.
- Trismus (difficulty opening the mouth).
- Ipsilateral otalgia (earache) and headache associated with fever, lethargy, and ipsilateral lymphadenopathy.
- Patients often develop a "plummy" voice due to oropharyngeal swelling.
Signs of PTA
- Limited mouth opening (trismus) is a hallmark sign.
- The tonsil is displaced medially by the hyperemic, bulging mucosa of the anterior pillar.
- Tender and enlarged jugulodigastric nodes.
Investigations in PTA
- Needle aspiration of pus.
- Transoral ultrasound.
- Computed tomography (CT).
- Magnetic resonance imaging (MRI) angiography, particularly for suspected vascular anomalies.
Treatment for PTA
- Admission and intravenous antibiotics.
- Drainage by needle aspiration or using a guarded quinsy knife is indicated in:
- Obvious pointing abscess.
- Clinical deterioration.
- Failure to respond to intravenous antibiotics.
- Evidence of pus in the peritonsillar space on imaging.
- Elective tonsillectomy is recommended after recurrent quinsy (6-8 weeks).
Complications of PTA
- Mediastinitis (infection of the mediastinum) has substantial mortality (23%).
- Necrotizing fasciitis following PTA is rarely described.
Parapharyngeal space
- Located on either side of the superior part of the pharynx.
- Bounded laterally by the parotid gland, parotid fascia, and medial pterygoid muscle.
- Medially bounded by the superior constrictor muscles.
- Superiorly limited by the skull base.
- Inferiorly bounded by fascia surrounding the submandibular gland.
- Posteriorly communicates with the retropharyngeal space.
Parapharyngeal space compartments
- Prestyloid compartment: Muscular compartment containing fat, connective tissue, and lymph nodes; bounded medially by the tonsillar fossa and laterally by the medial pterygoid muscle.
- Poststyloid compartment: Neurovascular compartment containing the carotid sheath, cranial nerves IX, X, XI, XII, and the sympathetic chain.
Parapharyngeal abscess
- Can occur in any age group.
- Most common causes:
- Tonsillitis.
- PTA.
- Dental infection.
- Less common causes:
- Elective tonsillectomy.
- Mastoiditis.
- Pharyngeal foreign body.
- Trauma from nasotracheal intubation.
- Internal cysts and fistulae of branchial origin.
- Second pharyngeal pouches.
Bacteriology of paraphynageal abscess
- Klebsiella pneumoniae.
- Streptococcus viridans.
- Pseudomonas aeruginosa (in patients with HIV disease).
Clinical features of parapharyngeal abscess
- Similar to PTA.
- Maximum swelling in the pharynx is more inferiorly placed, behind the tonsil.
- Less edema of the palate.
Signs of parapharyngeal abscess
- Tender, firm, and fluctuant swelling in the neck.
Differential diagnosis of parapharyngeal abscess
- Infectious: PTA, spinal tuberculosis.
- Neoplastic: Primary tumors of the parapharyngeal space (deep lobe parotid tumors), local spread from tonsil tumors, lymphoma.
- Vascular lesions: Pseudoaneurysms of the common, internal carotid, and lingual arteries.
Investigations for parapharyngeal abscess
- Plain X-ray lateral view of the neck to demonstrate foreign body penetration.
- CT and MRI of the head and neck, especially if mastoiditis is suspected.
- CT and MRI of the chest if mediastinitis is suspected.
Treatment for paraphynageal abscess
- Admission and intravenous antibiotics.
- Surgical drainage is recommended if there is no response to conservative treatment or clinical deterioration.
- Traditional drainage site: Incision at the level of the hyoid bone on the side of the neck.
Complications of parapharyngeal abscess
- Carotid sheath involvement.
- Acute pharyngeal perforation secondary to cervical necrotizing fasciitis.
- Mediastinitis.
- Descending necrotizing fasciitis of the neck and mediastinum.
- Upper airway obstruction.
Retropharyngeal space
- Bounded anteriorly by the pharynx and esophagus (buccopharyngeal fascia).
- Bounded posteriorly by the alar layer of deep fascia.
- Superiorly bounded by the skull base.
- Inferiorly bounded by the superior mediastinum.
- Contains retropharyngeal nodes.
Retropharyngeal abscess
- Most common in children under 6 years of age, with a peak incidence between 3-5 years old.
- Usually due to a suppurating retropharyngeal node following an upper respiratory tract infection (URTI).
- Rare in adults and children, but can occur secondary to foreign body penetration.
- Tuberculous retropharyngeal abscess is very rare, even in the presence of tuberculous cervical spondylitis (incidence 0.3-1%).
Bacteriology of retropharyngeal abscess
- Streptococcus viridans (most common).
- Staphylococcus epidermis.
- Staphylococcus aureus.
- Penicillin-resistant Streptococcus pneumoniae (described in pediatric cases).
Clinical features of retropharyngeal abscess in young children
- Neck stiffness, fever, irritability, dysphagia, and airway obstruction.
- Examination may reveal a bulging posterior pharyngeal wall.
Diagnosis of retropharyngeal abscess in infants and young children
- Easily overlooked and should be considered in the differential diagnosis of fever and irritability, especially when lumbar puncture results are normal.
Clinical features of retropharyngeal abscess in adults
- History of previous TB contact or pharyngeal trauma (fish bone, chicken bone) should be sought.
- Pain develops relatively late and may be associated with fever.
- Neurological signs can occur due to cord compression.
- Examination may reveal bulging of the posterior pharyngeal wall.
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Description
This quiz covers essential information about peritonsillar abscess (PTA), including its definition, common causes, and clinical features. Learn about the bacteriology involved and the age group most affected by this condition. Test your understanding of PTA and its implications in clinical practice.
