A 14 year old male presents with a very sore throat and fever. The symptoms have been present for 4 days. His PMD saw him 2 days ago and performed a rapid strep test, and it was negative. Since then he has gotten worse and it is hard for him to open his mouth fully. Per his mother it sounds like he just ate really hot food when he tries to speak. It is also quite painful to swallow, and he is having trouble swallowing all of his saliva. The RN caring him had already collected a rapid strep and it was negative.
On exam you note an ill appearing teenager with fever, HR in the 100-110 range and normal BP. He has tries us on exam, and it is somewhat difficult to understand what he is saying. When you examine his pharynx you see this.
What is the diagnosis?
This is a peritonsillar abscess (PTA). The hallmark clinical findings of which include:
- Severe unilateral throat pain and possibly ear pain
- Fever > 103F (39°C), malaise, rigors
- Difficulty swallowing saliva
- Muffled/hot-potato voice
- Unilateral redness and edema of the tonsillitis area with palpable fluctuance
- Unilateral anterior cervical lymphadenopathy
- Uvula deviated towards the contralateral side
A PTA is a complication of tonsillitis and is usually caused by beta hemolytic group A strep. Staph app. And Haemophilus spp. Are also known etiologies. It is more rare in preschool age children, as the lymph tissue is predominantly located in the retro pharynx, thus accounting for the prevalence of retropharyngeal abscesses. Most cases in pediatrics will be seen in teens.
What is the management?
The management includes needle aspiration or incision and drainage and antibiotics. Procedures should be performed in a center with an experienced practitioner with appropriate resources. Check out the embedded video from Anand Swaminathan as well as this post from Academic Life in Emergency Medicine for the more on the technique.
Even if the rapid strep is negative the pus cultured from head infections is often polymicrobial. Thus, beta lactamase coverage (including consideration for anaerobes) is reasonable. Ampicillin/Sulbactam as IV and Amoxicillin/Clavulanate as oral are reasonable choices. Cephalexin +/- Metronidazole or Clindamycin are options for Penicillin allergic patients. Patients that have moderate dehydration and are unable to tolerate PO, or those that are ill appearing should be admitted. Outpatient follow up is necessary in the next 48-72 hours.
Dexamethasone may reduce and hasten recovery pain in patients with PTA. Ozbek et al noted that a series of 62 hospitalized adolescents with PTA had faster resolution when they got Dexamethasone prior to the antibiotic course. Other studies have not shown as large of a benefit. I do tend to give a single dose in the ED at 0.6 mg/kg (max 10mg).