Peritonsillar abscess

Classification according to ICD-10
J36	Peritonsillar abscess
ICD-10 online (WHO version 2019)

A peritonsillar abscess is the formation of an abscess in the loose connective tissue surrounding the tonsils . The peritonsillar abscess is the most common complication of inflammatory tonsil disease.

Origin and course

There is often a history of several previous anginas in the history of peritonsillar abscesses .

The peritonsillar abscess occurs predominantly in the wake of acute tonsillitis (angina), but it can also develop from chronic tonsillitis without any previous acute symptoms . While the inflammatory process in angina is limited to the tonsils, in the case of a peritonsillar abscess the inflammation penetrates through the capsule of the tonsil into the surrounding loose connective tissue and leads to an accumulation of pus there. Most of the abscesses start from the upper part of the almond, which is why they usually spread above the almond. In addition to the streptococci , which are usually the cause, there are also anaerobic germs in the pus , which are responsible for the foul smell of the pus. If left untreated, the peritonsillar abscess breaks through the anterior palatal arch in front of the tonsil or the soft palate above the tonsil after five to ten days, and abundant stinking pus empties, which in uncomplicated cases leads to healing.

A peritonsillar abscess can also be the starting point for serious complications, such as abscesses of the cervical lymph nodes, spread of the inflammation along the vascular sheath of the neck with the development of thrombophlebitis and the risk of sepsis, and Lemierre's syndrome . The spread of the inflammation into the peripharyngeal space is particularly feared because it is in direct contact with the mediastinum and the inflammation can easily spread into the chest in this way.

Symptoms and diagnosis

If, as is usually the case, preceded by angina, the fever rises again after an initial improvement and an extremely severe sore throat on the side of the developing abscess. Swallowing in particular becomes almost impossible and leads to severe pain that radiates into the ear area, so that food intake is often refused. In most cases, an inflamed jaw clamp also occurs, so that the mouth can only be opened a little. Bad breath and a "lumpy" language are also typical. The regional lymph nodes in the corner of the jaw are swollen and painful.

The examination is difficult because of the jaw clamp, one can see a reddened, pronounced protrusion of the anterior palatal arch and the soft palate. The uvula is typically swollen and displaced from the midline to the opposite side. The almond itself is often covered by the swollen palatal arch.

The diagnosis arises from the typical symptoms and the typical local findings.

treatment

In the case of a peritonsillar abscess, a decision should be made on a case-by-case basis on the basis of the first occurrence, a relapse and the general symptoms. Incisional drainage or needle puncture represent a treatment option with few complications in the uncomplicated first event according to Herzon. In 2003, in his evidence-based literature review, Johnson did not find any superiority of the two methods incision or tonsillectomy . Based on a meta-analysis of studies, Stuck (2005) recommends an incision first if the picture is uncomplicated, otherwise an immediate tonsillectomy, and for both procedures antibiotics for at least 1 week.

The recommendation of the AWMF guideline published in August 2015 reads (quote): Needle puncture, incisional drainage and abscess tonsillectomy (tonsillectomy à chaud) have proven effective for the treatment of peritonsillar abscesses. When selecting the therapy method, the patient's ability to cooperate should be taken into account. Simultaneous antibiotic therapy should be carried out. Abscess tonsillectomy is preferred if complications have arisen from the peritonsillar abscess or if alternative therapy methods have not been successful. Simultaneous tonsillectomy on the opposite side should only be performed if the recommendation for tonsillectomy listed above or there is evidence of a bilateral peritonsillar abscess. Needle puncture / incisional drainage is preferred if there are comorbidities, an increased risk of surgery or coagulation disorders. An interval tonsillectomy (ITE) should not be done as there are no studies that show any benefit from ITE. In addition, peritonsillar abscess recurrences after needle puncture and / or incisional drainage are rare.

literature

• E. Lüscher: Textbook of nose and throat medicine. Springer-Verlag, Vienna 1956.
• W. Becker, HH Naumann, CR Pfaltz: Ear, nose and throat medicine. Thieme Verlag, Stuttgart 1983.

Individual evidence

1. ↑ FS Herzon: Peritonsillar abscess: incidence, current management practices, and a proposal for treatment guidelines. In: Laryngoscope . tape 105 , 8 Pt 3 Suppl 74, 1995, p. 1-17 , PMID 7630308 .
2. ^ RF Johnson, MG Stewart, CC Wright: An evidence-based review of the treatment of peritonsillar abscess . In: Otolaryngology - Head and Neck Surgery . tape 128 , no. 3 , 2003, p. 332-343 , PMID 12646835 .
3. ↑ Boris A. Stuck, Jochen P. Windfuhr, Harald Genzwürker, Horst Schroten, Tobias Tenenbaum, Karl Götte: The tonsillectomy in childhood . In: Deutsches Ärzteblatt . tape 105 , no. 49 , 2008, p. 852-860 , PMID 19561812 ( online article [accessed September 29, 2013]).
4. ↑ Guideline "Inflammatory diseases of the tonsils / tonsillitis, therapy" available as a PDF document

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