Bilateral peritonsillar cellulitis

Bilateral peritonsillar cellulitis

An acute infection located between the tonsil and the superior pharyngeal constrictor muscle.

Peritonsillar abscess (quinsy) is rare in children but more common in young adults. Although usually due to a group A -hemolytic streptococcus, peritonsillar infection can also be caused by anaerobic microorganisms, such as bacteroides. Swallowing causes severe pain; the patient is febrile and toxic, tilts the head toward the side of the abscess, and has marked trismus. The tonsil is displaced medially by the peritonsillar cellulitis and abscess, the soft palate is erythematous and swollen, and the uvula is edematous and displaced to the opposite side.

Treatment

Cellulitis without pus formation responds to penicillin in 24 to 48 h. Initially, penicillin G 1 million U IV q 4 h is given. If pus is present and does not drain spontaneously, aspiration or incision and drainage are required. Antibiotic therapy with penicillin V 250 mg q 6 h should be continued orally for 12 days unless cultures and sensitivity studies indicate that another antibiotic is preferable. Peritonsillar abscesses may recur, and tonsillectomy may be considered, especially for patients with recurrent abscesses. It is usually performed 6 wk after the acute infection has subsided, but if antibiotic therapy is given, it can be performed during the acute infection.

Merck Manual

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Peritonsillar abscess (Quinsy)

Suppurative complication of streptococcal tonsillitis with formation of abscess containing range of oropharyngeal flora, including anaerobes. Risk factor from not giving antibiotics but many develop quinsy even after being given penicillin for sore throat.

EpidemiologyIncidence Now relatively uncommon

Presentation

Symptoms

Very painful sore throat with difficulty in opening mouth (trismus - present in 60%). Fever, malaise, headache, swelling in neck, referred ear pain and dysphagia. "Plummy" or "hot potato voice"Signs Displacement of the tonsil on the affected side towards the midline ±exudate. Fluctuant mass may be felt in affected area; fetor oris, drooling and excessive salivation. Cervical lymphadenopathy ++

Common Causative Organisms

Streptococcus pyogenes(30%), Streptococcus milleri, Haemophilus influenzae, Staphylococcus aureus, peptostreptococcal microbes and other anerobes.3

Differential Diagnosis

Peritonsillar cellulitis (peritonsillitis) - responds to antibiotics without need for drainage (ie no abscess)

Management

Broad spectrum antibiotics - High dose penicillin, or combination therapy of a penicillin and metronidazole depending on local degree of penicillin resistance.

Surgical - Incision or needle aspiration

Elective tonsillectomy may be required. Emergency tonsillectomy is not usually recommended (higher cost and complication rates).

Complications

Infection may spread into neck and surrounding tissues. Airway obstruction (rare) - may require cricothyroidotomy or tracheotomy. Rupture of abscess may result in aspiration pneumonitis or pneumonia.

References Used

Cecil Textbook of Medicine 18th Edition. Eds Wingaarden JB & Smith LH. WB Saunders 1988 p.1576
Mehanna HM, Al-Bahnasawi L, White A; National audit of the management of peritonsillar abscess.;Postgrad Med J 2002 Sep; 78(923):545-8.
eMedicine - Quinsy

Acknowledgements

EMIS is grateful to doctoronline.nhs.uk for facilitating draft authoring of this article. The final copy has passed peer review of the independent Mentor GP authoring team. ©EMIS 2003.

Patient UK

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Related Abstracts:

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Demographics of pediatric head and neck infections in a tertiary care hospital.

Schweinfurth JM.

Department of Otolaryngology-Head and Neck Surgery, Laryngology and Voice Disorders, University of Mississippi Medical Center, Jackson, Mississippi 29216, USA.

JSchweinfurth@ent.umsmed.edu

EDUCATIONAL OBJECTIVE:

Discuss potential patterns in the epidemiology of infectious disease of the head and neck.

STUDY OBJECTIVES: To investigate patterns in the epidemiology of severe head and neck infections that may reflect the impact of host factors.

STUDY DESIGN: Population-based, historic cohort study.

METHODS: Information on 1,010, incident head and neck infections occurring over a 5-year period was reviewed for demographics, location, and time of year. A nonparametric Kruskal-Wallis test was used to identify significant differences in the age distributions among the diagnosis groups. A Bonferroni, pair-wise comparison procedure was used for comparison of the average age of first onset of severe head and neck infections. Chi-square test was used to identify any significant association between season of the year and disease.

RESULTS: Significant differences were identified in the age distributions among the diagnosis groups (P < .001). The average age of first onset of cellulitis of the neck and retropharyngeal abscess is earlier than peritonsillar abscess, at 2 to 3 years and 13 years, respectively. Parapharyngeal and periapical abscesses and cellulitis of the face occur at approximately age 6. The incidence of parapharyngeal abscess and diseases of the pharynx is decreased during Spring, whereas peritonsillar abscesses and acute periodontitis occurs more often in Spring and Summer. Age does not appear to be related to season of first occurrence.

CONCLUSIONS: Head and neck infections are not random occurrences based on exposure alone; host factors are clearly important. Given the lack of correlation with school age, the results cannot be explained on the basis of exposure alone. Developmental patterns of the host immune response may be related to the age differential identified in the current study and are cause for further investigation.

PMID: 16735893 [PubMed - indexed for MEDLINE]

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The role of anaerobic bacteria in tonsillitis.

Brook I.

Department of Pediatrics, Georgetown University School of Medicine, 4431 Albemarlr St. NW, Washington, DC 20016, USA. ib6@georgetown.edu

This review summarizes the information that supports the potential importance of anaerobic bacteria in tonsillitis. Some anaerobic bacteria possess interfering capability with Group A beta-hemolytic streptococci (GABHS) and other pathogens. The possible role of anaerobes in the acute inflammatory process in the tonsils is supported by several observations: anaerobes have been isolated from the cores of tonsils of patients with recurrent GABHS and non-GABHS tonsillitis (NST); the recovery of anaerobes as predominant pathogens in abscesses of tonsils, in many cases without any aerobic bacteria; their recovery as pathogens in well-established anaerobic infections of the tonsils (Vincent's angina); the increased recovery rate of encapsulated pigmented Prevotella and Porphyromonas spp. in acutely inflamed tonsils; their isolation from the cores of recurrently inflamed NST; and the response to antibiotics in patients with NST. Furthermore, immune response against Prevotella intermedia is present in patients with recurrent NST, and an immune response can also be detected against P. intermedia and Fusobacterium nucleatum in patients who recovered from peritonsillar cellulitis or abscesses, infectious mononucleosis and acute non-streptococcal and GABHS tonsillitis. Although more studies are needed, these findings support the possible pathogenicity of Gram-negative anaerobic bacilli in tonsillitis.

Publication Types:
ReviewPMID: 15627441 [PubMed - indexed for MEDLINE]

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Peritonsillar infections: local experience.

Ong YK, Goh YH, Lee YL.Department of Otolaryngology, Singapore General Hospital, Outram Road, Singapore 169608. ykong@pacific.net.sg

INTRODUCTION: The disease pattern and management of peritonsillar infections in Singapore General Hospital are studied. Other objectives are to determine if a seasonal variation exists and to examine the role of routine bacterial cultures and interval tonsillectomy.

METHODS: This is a retrospective review of the management and outcome of patients with peritonsillar infections who were admitted acutely to Singapore General Hospital over a three-year period.

RESULTS: Of 185 patients studied, 151 (81.6 percent) had peritonsillar abscess or quinsy and 34 (18.4 percent) had peritonsillar cellulitis. There were 139 males and 46 females, with a racial predisposition among Malays (p value is less than 0.0005). There may be a seasonal variation with a bi-annual trend, though no correlation with upper respiration tract infections was noted. Treatment consisted mainly of incision and drainage (66 percent) or needle aspiration (34 percent). No significant difference in the length of stay was noted in patients receiving penicillin alone, penicillin with metronidazole, or broad-spectrum antibiotics (p value is equal to 0.062). Fourteen (7.6 percent) patients had recurrences, all of which occurred after the first month. Two patients (1 percent) had bilateral quinsy.

CONCLUSION: Peritonsillar infections remain a common admitting diagnosis to the Otolaryngology department. A single episode of infection should no longer be an indication for tonsillectomy as the incidence of recurrence is low.

Full Text Article and Case Study