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Pediatrics: General Medicine > Infectious Disease
Peritonsillar Abscess
Article Last Updated: Jul 30, 2008
AUTHOR AND EDITOR INFORMATION
Section 1 of 12  
Author: Itzhak Brook, MD, MSc, Professor, Department of Pediatrics, Georgetown University School of Medicine
Itzhak Brook is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, Armed Forces Infectious Diseases Society, Association of Military Surgeons of the US, Infectious Diseases Society of America, International Immunocompromised Host Society, International Society for Infectious Diseases, Medical Society of the District of Columbia, New York Academy of Sciences, Pediatric Infectious Diseases Society, Society for Ear, Nose and Throat Advances in Children, Society for Experimental Biology and Medicine, Society for Pediatric Research, Southern Medical Association, and Surgical Infection Society
Editors: Ashir Kumar, MBBS, MD, FAAP, Professor, Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University; Consulting Staff, Department of Pediatrics, EW Sparrow Hospital; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Joseph Domachowske, MD, Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York-Upstate Medical University; Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine; Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Author and Editor Disclosure
Synonyms and related keywords:
peritonsillar abscess, PTA, quinsy, palatine tonsil, peritonsillar cellulitis, PTC, Weber glands, bacterial tonsillitis, group A streptococci, trismus, "hot potato" voice, velopharyngeal insufficiency, respiratory distress, halitosis, sore throat
Background
Peritonsillar abscess (PTA) is a suppurative infection of the tissues adjacent to the palatine tonsil and is the most common abscess of the head and neck region.
Pathophysiology
The development of the abscess is often gradual, with an early stage of peritonsillar cellulitis. If not properly treated, an abscess emerges. Two mechanisms have been proposed to explain the development of a collection of pus in the loose connective tissue of the supratonsillar fossa. The more common explanation is that a PTA develops from the direct spread of an inadequately treated bacterial tonsillitis. An alternative explanation is that PTA is an abscess formed in a group of salivary glands in the supratonsillar fossa, known as Weber glands. Lymphatic drainage from an infected PTA is to the ipsilateral jugulodigastric nodes. Bacterial cultures that are also adequate for the recovery of anaerobic bacteria usually yield polymicrobial aerobic and anaerobic bacteria. Group A beta-hemolytic streptococci is recovered in 25-40% of the abscesses.
Frequency
United States
The estimated incidence is 30 per 100,000 person-years in patients aged 5-59 years.1 Approximately 25-30% of patients with PTA are in the pediatric age group.
Mortality/Morbidity
The mortality rate is unknown. Mortality is often due to aspiration of a ruptured abscess or sequelae of sepsis. Morbidity stems principally from pain and dehydration. See Complications in the Follow-up section.
Race
No race predilection is known.
Sex
No sex predilection is reported.
Age
PTA most commonly occurs in the third and fourth decades of life. Pediatric cases are more common in children older than 10 years, although cases have been described in children younger than 1 year.
History
- Sore throat/dysphagia
- Usually for 5-7 days
- Not improving on antibiotics
- Trismus
- Pain when mouth is opened wide
- Secondary to inflammation of internal pterygoid muscle
- Fever
- Drooling
- Muffled voice
- Also called "hot potato" voice
- Secondary to dysfunction of the palatal muscles on the affected side, resulting in velopharyngeal insufficiency
- Referred ear pain
Physical
- Moderately uncomfortable appearing
- Febrile
- Potential respiratory distress
- Difficulty opening mouth (trismus)
- Oropharynx symptoms (see Media file 1)
- Asymmetric swelling of the soft tissues is lateral and superior to the affected tonsil with displacement of the affected tonsil medially and anteriorly.
- Fluctuant area is palpable.
- Appearance of tonsil may be normal or may show erythema and exudates.
- Uvula is displaced to the contralateral side.
- Soft palate is red and swollen.
- Involvement is bilateral in 3% of cases.
- Halitosis
- Cervical (jugulodigastric) adenopathy
Causes
- A positive culture of aerobic and/or anaerobic pathogens is observed in 60-80% of aspirates.
- Bacterial growth is often polymicrobial, including aerobic and anaerobic bacteria of oral flora origin. More than half of the aerobic (ie, Staphylococcus aureus) and anaerobic (ie, Prevotella, Porphyromonas, and Fusobacterium species) isolates can be beta-lactamase producers.
- Aerobic bacteria implicated in peritonsillar abscess (PTA) include the following:
- Group A beta-hemolytic Streptococcus pyogenes (most commonly isolated aerobe)
- Staphylococcus aureus (methicillin susceptible or methicillin resistant)
- Alpha-hemolytic streptococci
- Coagulase-negative staphylococci
- Streptococcus pneumoniae (penicillin susceptible or penicillin resistant)
- Anaerobes implicated in PTA include the following:
- Anaerobic gram-negative bacilli (eg, pigmented Prevotella and Porphyromonas species, Bacteroides species)
- Peptostreptococcus species
- Fusobacterium species
- Differentiating between PTA and peritonsillar cellulitis is often difficult because the pathogenesis is similar and patients present with similar symptoms.2 Only patients with a PTA require a drainage procedure, whereas patients with either PTA or peritonsillar cellulitis are treated with antibiotics.
- Clinical signs such as trismus and inconsistent drooling have been associated more often with PTA. No method to differentiate between the two is perfect; however, current methods include the following:
- Observing the patient's response to 24-48 hours of intravenous antibiotics
- Attempting needle aspiration of the site
- Using an imaging modality such as CT scanning or ultrasonography
Dental Abscess
Lymphoproliferative Disorders
Pharyngitis
Retropharyngeal Abscess
Other Problems to be Considered
Epstein-Barr virus
Peritonsillar cellulitis (peritonsillitis)
Lateral pharyngeal space abscess
Tonsillar abscess
Carotid artery aneurysm
Extensive cervical adenitis
Mastoid infection
Salivary gland infection
Cervical infection
Sublingual abscess
Prevertebral abscess
Lab Studies
Laboratory tests are unnecessary if the diagnosis is straightforward. - Obtain a CBC count with differential.
- CBC may show a leukocytosis with neutrophil predominance.
- With infectious mononucleosis, expect lymphocyte predominance with atypical lymphocytosis.
- Culture and sensitivity for aerobic and anaerobic bacteria of purulent material from needle aspiration can be performed.
- Some experts believe this is unnecessary because almost all patients respond following drainage and antibiotic therapy, regardless of culture results.
- If testing is desired, send material for both aerobic and anaerobic cultures in appropriate media and not on swabs. Culture may be sterile if the patient is currently taking antibiotics.
Imaging Studies
Imaging studies are unnecessary if the diagnosis is straightforward.
- CT scan with intravenous contrast may be performed (see Media file 2).3
- This study is indicated when the diagnosis is unclear, when the patient is uncooperative with the examination, and when the infectious process is thought to involve deeper structures.
- An abscess appears as a low-attenuation mass with a ring-enhancing wall. Presence of only soft tissue swelling and edema (but no mass) is consistent with peritonsillitis.
- A sensitivity of 100% and specificity of 75% are reported.
- Ultrasonography is indicated for differentiating between peritonsillitis and peritonsillar abscess (PTA).4
- The intraoral approach is more accurate than the transcutaneous approach.
- An abscess usually has an isoechoic rim with a hypoechoic center; however, some abscesses have a homogeneous isoechoic pattern.
- A sensitivity of 89% and specificity of 100% are reported.
Medical Care
Three areas to be addressed are hydration, analgesia, and antibiotics. The mode of delivery (intravenous [IV] vs oral [PO]) depends on the patient's ability to tolerate PO intake and on the decision to treat the patient as an inpatient or outpatient.
Surgical Care
Three drainage procedures are needle aspiration, incision and drainage, and tonsillectomy.
- Needle aspiration
- This procedure is indicated either as the definitive drainage procedure or to confirm the presence of pus prior to incision and drainage.
- After the identified area of fluctuance is anesthetized (in 90% of cases, this is the superior-medial aspect of the tonsil), an 18-gauge spinal needle is inserted, and pus is aspirated with a 10-mL syringe.
- Some authorities recommend 3-point aspiration, with the first site being superior and medial and the other 2 sites progressively 0.5-1 cm more inferior and lateral.
- Complications include respiratory distress, aspiration, and hemorrhage.
- The success rate of needle aspiration exceeds 90%. If symptoms do not resolve with needle aspiration, the patient may either undergo a second needle aspiration or one of the other 2 drainage procedures.
- Needle aspiration may be performed by a well-trained nonotorhinolaryngologist.
- Contraindications to performing needle aspiration in the outpatient setting are (1) uncertain diagnosis, (2) uncooperative child, (3) very young child, and (4) anticipation of airway management problems.
- Incision and drainage
- The procedure achieves wider drainage than with needle aspiration.
- It is more painful than needle aspiration.
- The procedure requires an otorhinolaryngologist to perform it.
- Contraindications to performing incision and drainage in the outpatient setting are (1) uncertain diagnosis, (2) uncooperative child, (3) very young child, and (4) anticipation of airway management problems.
- Tonsillectomy
- When performed in the acute stages of a peritonsillar abscess (PTA), the procedure also is known as an abscess tonsillectomy, quinsy tonsillectomy, cold tonsillectomy, and tonsillectomy à chaud. When performed after an interval of several weeks, this procedure is known as interval tonsillectomy.
- Tonsillectomy is preferred by some authorities because it is definitive therapy, may decrease the overall duration of inpatient stay if interval tonsillectomy is to be performed at a later date, and carries no increased morbidity over interval tonsillectomy.
- The downsides to this procedure are that it must be performed in the operating room (which leads to increased costs and time delays) and that intubating the patient may prove difficult.
- Only an otorhinolaryngologist should perform tonsillectomy.
Consultations
- Consult an otorhinolaryngology in all cases for follow-up care.
- Directly involve an ear, nose, and throat (ENT) physician in the following cases:
- All children with an unclear diagnosis
- Anyone undergoing incision and drainage in the emergency department
- All patients (very young, uncooperative) who require abscess tonsillectomy in the operating room
Diet
When airway compromise is a concern, the patient should be restricted to nothing by mouth (NPO). Otherwise, diet should consist of fluids and a soft diet as tolerated.
Activity
Permit activity as tolerated.
Drugs used in the treatment of peritonsillar abscess (PTA) primarily include antibiotics and analgesics. Some otorhinolaryngologists also recommend use of corticosteroids for their anti-inflammatory effect. Whether these medications are given PO or IV depends on whether the patient is able to tolerate PO and whether the patient is being treated as an inpatient or outpatient. For analgesia, use of a combined opioid plus acetaminophen preparation is preferred.
Drug Category: Antibiotics
For outpatient management, a beta-lactam antibiotic is preferred. Amoxicillin plus clavulanate (Augmentin) is the drug of choice (DOC). For inpatient management, IV ampicillin plus sulbactam is preferred. Alternatively, a combination of IV ceftriaxone and clindamycin or a carbapenem (ie, imipenem) is used for severe or complicated cases.
| Drug Name | Amoxicillin plus clavulanate (Augmentin) |
|---|
| Description | Interferes with synthesis of cell wall peptidoglycan during active replication, resulting in bactericidal activity against susceptible microorganisms. Clavulanic acid is a potent beta-lactamase inhibitor, further broadening the spectrum of activity to include beta-lactamase–producing S aureus and anaerobes (eg, Prevotella species).
For children >3 months, base dosing protocol on amoxicillin content. Because of different amoxicillin/clavulanic acid ratios in 250-mg tab (250/125) vs 250 mg chewable-tab (250/62.5), do not use 250-mg tab until child weighs >40 kg. |
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| Adult Dose | Doses expressed as mg of amoxicillin: 250-500 mg PO q8h or 875 mg PO q12h |
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| Pediatric Dose | <3 months: 125 mg/5mL PO susp; 30 mg/kg/d (based on amoxicillin component) divided bid for 7-10 d
>3 months: If using 200 mg/5 mL or 400 mg/5 mL susp, 45 mg/kg/d PO divided q12h; if using 125 mg/5 mL or 250 mg/5 mL suspension, 40 mg/kg/d PO divided bid for 7-10 d
>40 kg: Administer as in adults |
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| Contraindications | Documented hypersensitivity |
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| Interactions | May reduce PO contraceptive efficacy; probenecid increases amoxicillin levels; allopurinol coadministration may increase risk of rash |
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| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
|
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| Precautions | Modify dosing with severe renal disease |
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| Drug Name | Imipenem and cilastatin (Primaxin) |
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| Description | For treatment of multiple organism infections in which other agents do not have wide spectrum coverage or are contraindicated due to potential for toxicity. Provides anaerobic coverage. |
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| Adult Dose | Base initial dose on severity of infection, and administer in equally divided doses; dose may range from 250 to 500 mg q6h IV for a maximum of 3-4 g/d
Adjust dose in renal insufficiency:
CrCl 80-50 mL/min: 0.5 g POq6-8h
CrCl 50-10 mL/min: 0.5 g PO q8-12h
Hemodialysis: 0.25-0.5 g PO after HD, then q12h
Alternatively, 500-750 mg q12h IM or intra-abdominally |
|---|
| Pediatric Dose | Infants >3 months and children <12 years: 15-25 mg/kg/dose IV q6h
Fully susceptible organisms: not to exceed 2 g/d
Infections with moderately susceptible organisms: not to exceed 4 g/d
>12 years: Administer as in adults |
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| Contraindications | Documented hypersensitivity; known hypersensitivity to amide local anesthetics; children with CNS infections (increased seizure risk); children <30 kg with renal impairment (lack of data) |
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| Interactions | Coadministration with cyclosporine may increase CNS side effects of both agents; coadministration with ganciclovir may result in generalized seizures |
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| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
|
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| Precautions | Adjust dose in renal insufficiency; avoid use in children <12 y with CNS infections; caution with history of seizures, hypersensitivity to penicillins, cephalosporins, or other beta lactam antibiotics |
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| Drug Name | Ampicillin plus sulbactam (Unasyn) |
|---|
| Description | Interferes with synthesis of cell wall peptidoglycan during active replication, resulting in bactericidal activity against susceptible microorganisms. Clavulanic acid is a potent beta-lactamase inhibitor, further broadening the spectrum of activity to include beta-lactamase–producing S aureus and anaerobes (eg, Prevotella species). |
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| Adult Dose | Dose expressed as mg of ampicillin: 1-2 g IV q6-8h |
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| Pediatric Dose | Dose expressed as mg of ampicillin:
<1 year: Not established
>1 year: 100-200 mg/kg/d IV divided q6h |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Efficacy of PO contraceptives may be reduced; probenecid increases ampicillin levels; allopurinol coadministration may increase risk of rash |
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| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
|
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| Precautions | Dosing adjustments required for renal failure |
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| Drug Name | Clindamycin (Cleocin) |
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| Description | Alternative agent in patients allergic to penicillin. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. |
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| Adult Dose | 150-450 mg/dose PO q6-8h; not to exceed 1.8 g/d
600-3600 mg/d IV divided q6-8h depending on severity of infection |
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| Pediatric Dose | 20-30 mg/kg/d PO divided q6h; not to exceed 1.8 g/d
25-40 mg/kg/d IV divided q6-8h |
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| Contraindications | Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis |
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| Interactions | Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin |
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| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
|
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| Precautions | Based on number of exposed patients, clindamycin is most frequent cause of Clostridium difficile toxin–mediated diarrhea; adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency |
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| Drug Name | Ceftriaxone (Rocephin) |
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| Description | Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Bactericidal activity results from inhibiting cell wall synthesis by binding to one or more penicillin binding proteins. Exerts antimicrobial effect by interfering with synthesis of peptidoglycan, a major structural component of bacterial cell wall. Bacteria eventually lyse due to the ongoing activity of cell wall autolytic enzymes while cell wall assembly is arrested.
Highly stable in presence of beta-lactamases, both penicillinase and cephalosporinase, of gram-negative and gram-positive bacteria. Approximately 33-67% of dose excreted unchanged in urine, and remainder secreted in bile and ultimately in feces as microbiologically inactive compounds. Reversibly binds to human plasma proteins, and binding have been reported to decrease from 95% bound at plasma concentrations <25 mcg/mL to 85% bound at 300 mcg/mL.
|
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| Adult Dose | Uncomplicated infections: 250 mg IM once; not to exceed 4 g
Severe infections: 1-2 g IV qd, or divided bid; not to exceed 4 g/d |
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| Pediatric Dose | Neonates >7 d: 25-50 mg/kg/d IV/IM; not to exceed 125 mg/d
Infants and children: 50-75 mg/kg/d IV/IM divided q12h; not to exceed 2 g/d |
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| Contraindications | Documented hypersensitivity; hyperbilirubinemic neonates, particularly those who are premature |
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| Interactions | Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity |
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| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
|
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| Precautions | Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections, and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy; caution in breast-feeding women; may displace bilirubin from albumin binding sites increasing the risk of kernicterus; caution with gallbladder, biliary tract, liver or pancreatic disease; or in patients with history of colitis or penicillin hypersensitivity |
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Drug Category: Analgesic agents
Pain control is essential to quality patient care.
| Drug Name | Acetaminophen and codeine (Tylenol with Codeine Elixir) |
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| Description | Indicated for the treatment of mild to moderate pain. Contains codeine 12 mg and acetaminophen 120 mg per 5 mL. |
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| Adult Dose | 30-60 mg/dose based on codeine content PO q4-6h or 1-2 tab q4h; not to exceed 4 g/d of acetaminophen |
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| Pediatric Dose | 0.5-1 mg/kg/dose PO based on codeine q4-6h; 10-15 mg/kg/dose based on acetaminophen content; not to exceed 2.6 g/d of acetaminophen |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Toxicity of codeine increases with CNS depressants, tricyclic antidepressants, MAOIs, neuromuscular blockers, CNS depressants, phenothiazines, or narcotic analgesics; rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity of acetaminophen |
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| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
|
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| Precautions | Caution in patients dependent on opiates since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction; hepatotoxicity with acetaminophen possible in chronic use following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products and combined use with these products may result in cumulative acetaminophen doses and exceed recommended maximum dose |
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Further Inpatient Care
- Admit patients with the following conditions:
- Airway compromise
- Dehydration and inability to tolerate oral intake
- Uncertain outpatient compliance
- Unclear diagnosis
- Suspected local or systemic complications
- Toxic appearance
- Include IV fluids, IV antibiotics, and analgesia.
- Reevaluate patients daily for possible further surgical intervention including repeat aspiration, incision and drainage, or abscess tonsillectomy in the operating room.
Further Outpatient Care
- Arrange for follow-up in 24 hours.
- Arrange for patient reassessment for further surgical intervention such as elective tonsillectomy.
Transfer
- Transfer to an institution where ENT has experience in treating peritonsillar abscess (PTA) in children.
Deterrence/Prevention
- In patients with PTA who have a history of recurrent tonsillitis or PTA, interval tonsillectomy is recommended to prevent further episodes.
Complications
- Airway compromise
- Aspiration of abscess contents (spontaneously or with incision and drainage)
- Parapharyngeal abscess
- Septic thrombophlebitis involving the internal jugular vein or internal carotid artery leading to septicemia with metastatic foci of infection, especially in the lung (Lemierre disease, caused by Fusobacterium)
- Sepsis
- Hemorrhage as a result of iatrogenic injury to major vessels on attempted aspiration or incision and drainage
- Mediastinitis
- Contiguous spread to the pterygomaxillary space
Prognosis
- Prognosis is good for full recovery when patients are treated with a combination of a drainage procedure and the appropriate antibiotic therapy.
- After one aspiration, 80-90% of PTAs resolve.
- An additional 5-10% of PTAs resolve with repeat aspiration.
- If patients have not already undergone an abscess tonsillectomy, PTA is considered as a relative indication for interval tonsillectomy in the following patients:
- Patients who have had recurrent tonsillitis prior to PTA
- Patients who have a recurrent PTA
- In rare instances, PTA can recur after a bilateral tonsillectomy.
Patient Education
Medical/Legal Pitfalls
- Failure to differentiate between peritonsillar cellulitis and PTA because only PTA requires a drainage procedure
- Failure to address hydration, analgesia, and antibiotics
Special Concerns
- Young patients may not cooperate with a complete examination of the oropharynx. These patients may require diagnostic imaging (ie, CT scan) to establish diagnosis.
- Young patients may not cooperate with a bedside drainage procedure (eg, needle aspiration, incision and drainage). Take these patients to the operating room for appropriate management.
The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Gershon Segal, MD to the development and writing of this article.
| Media file 1:
Examination of the oropharynx demonstrates unilateral swelling and erythema of the left tonsil with deviation of the uvula to the contralateral side. Courtesy of Michael Altieri, MD, Medifor, Inc. Used with permission. |
 |  View Full Size Image | |
Media type: Photo
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| Media file 2:
CT scan with contrast demonstrates a 2-cm low-attenuation mass with a minimally enhancing wall in the right peritonsillar region. Associated edema, ipsilateral jugulodigastric lymphadenopathy, compression of the internal jugular vein, and deviation of the airway are present. |
 | View Full Size Image | |
Media type: CT
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Peritonsillar Abscess excerpt Article Last Updated: Jul 30, 2008
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