Throat abscesses
Throat abscesses: Excerpt from Professional Guide to Diseases (Eighth Edition)
Throat abscesses may be peritonsillar (quinsy) or retropharyngeal. Peritonsillar abscesses form in the connective tissue space between the tonsil capsule and the constrictor muscle of the pharynx. Retropharyngeal abscesses, or abscesses of the potential space, form between the posterior pharyngeal wall and the prevertebral fascia. With treatment, the prognosis for both types of abscesses is good.
Causes and incidence
Peritonsillar abscess is a complication of acute tonsillitis, usually after streptococcal or staphylococcal infection. It occurs more commonly in adolescents and young adults than in children.
Acute retropharyngeal abscess results from infection in the retropharyngeal lymph glands, which may follow an upper respiratory tract bacterial infection. Most common pathogens are beta-hemolytic Streptococcus and Staphylococcus aureus. These lymph glands begin to atrophy after age 2. Acute retropharyngeal abscess most commonly affects infants and children younger than age 2.
Chronic retropharyngeal abscess may result from tuberculosis of the cervical spine (Pott’s disease) and may occur at any age.
Signs and symptoms
Key symptoms of peritonsillar abscess include severe throat pain, occasional ear pain on the same side as the abscess, and tenderness of the submandibular gland. Dysphagia causes drooling. Trismus may occur as a result of the spread of edema and infection from the peritonsillar space to the pterygoid muscles. Other effects include fever, chills, malaise, rancid breath, nausea, muffled speech, dehydration, cervical adenopathy, and localized or systemic sepsis.
Clinical features of retropharyngeal abscess include pain, dysphagia, fever and, when the abscess is located in the upper pharynx, nasal obstruction; with a low-positioned abscess, dyspnea, progressive inspiratory stridor (from laryngeal obstruction), neck hyperextension and, in children, drooling and muffled crying occur. Other symptoms in children may include gurgling respirations, dyspnea and dysphagia, respiratory symptoms, and fever. A very large abscess may press on the larynx, causing edema, or may erode into major vessels, causing sudden death from asphyxia or aspiration.
Diagnosis
Diagnosis of peritonsillar abscess usually begins with a patient history of bacterial pharyngitis. Examination of the throat shows swelling of the soft palate on the abscessed side, with displacement of the uvula to the opposite side; red, edematous mucous membranes; and tonsil displacement toward the midline. Culture may reveal streptococcal or staphylococcal infection.
Diagnosis of retropharyngeal abscess is based on patient history of nasopharyngitis or pharyngitis and on physical examination revealing a soft, red bulging of the posterior pharyngeal wall. X-rays show the larynx pushed forward and a widened space between the posterior pharyngeal wall and vertebrae. If neck pain or stiffness occurs, look for extension to the epidural space or the cervical vertebrae. Culture and sensitivity tests isolate the causative organism and reveal the appropriate antibiotic.
Treatment
For early-stage peritonsillar abscess, large doses of penicillin or another broad-spectrum antibiotic are necessary. If the patient is immunocompromised or has been repeatedly hospitalized, antibiotic therapy should include coverage for staphylococci and gram-negative organisms. For late-stage abscess, with cellulitis of the tonsillar space, primary treatment is usually incision and drainage under a local anesthetic, followed by antibiotic therapy for 7 to 10 days. Tonsillectomy, scheduled no sooner than 1 month after healing, prevents recurrence but is recommended only after several episodes.
In acute retropharyngeal abscess, the primary treatment is incision and drainage through the pharyngeal wall. It’s considered a surgical emergency. In chronic retropharyngeal abscess, drainage is performed through an external incision behind the sternomastoid muscle. During incision and drainage, strong, continuous mouth suction is necessary to prevent aspiration of pus, and the head should be kept down. Postoperative drug therapy includes I.V. antibiotics (usually penicillin or clindamycin) and analgesics.
Special considerations
❑ Be alert for signs of respiratory obstruction (inspiratory stridor, dyspnea, retractions and nasal flaring, increasing restlessness, and cyanosis). Keep emergency airway equipment nearby.
❑ Explain the drainage procedure to the patient and his parents. Because the procedure is usually done under local anesthesia, the patient may be apprehensive.
❑ Assist with incision and drainage. To allow easy expectoration and suction of pus and blood, place the patient in a semirecumbent or sitting position.
After incision and drainage:
❑ Give antibiotics, analgesics, and antipyretics, as ordered. Stress the importance of completing the full course of prescribed antibiotic therapy.
❑ Monitor vital signs, and report significant changes or bleeding. Assess pain, and treat accordingly.
❑ If the patient is unable to swallow, ensure adequate hydration with I.V. therapy. Monitor fluid intake and output, and watch for dehydration.
❑ Provide meticulous mouth care. Apply petroleum jelly to the patient’s lips. Promote healing with warm saline gargles or throat irrigations for 24 to 36 hours after incision and drainage. Encourage adequate rest.
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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