Peritonsillar Abscess

Imaging

100

Name this imaging modality 

CT soft tissue neck with IV contrast

200

What is happening here? 

Intraoral ultrasound for diagnosis of PTA 

300

I am concerned that the infection has spread outside peritonsillar space. My patient reports a iodine contrast allergy (my throat closes up). My next option includes 

MRI 

400

Describe this approach for visualization of PTA 

submandibular transcutaneous ultrasound: aim transducer anterior-posteriorly 

midline approach with tranducer held transversely at midline near suprahyoid neck 

Looking for hypoechoic or anechoic fluid filled cavity 

500

Name this approach: 

Transverse or midline approach approach. 

Midline approach is with  tranducer held transversely at midline near suprahyoid neck

In children and some adolescents, pay perform transvervical approach. 

Antibiotics

100

True or false: All patients who come into the ED with evidence of peritonsillar abscess should at least be admitted to CDU for IVF, IV Abx, and dose of steroids 

No, often patients can return home, some not even requiring antibiotics in some cases. 

200

What are the optimal IV antibiotics for adults who present with PTA? 

Penicillin 10 million U q6 and metronidazole 500mg q6

Unasyn 3g q6 hrs 

Clindamycin 900 mg q8hrs Ceftriaxone 1g q12hrs plus metronidazole 500mg q6hrs 

Zosyn 3.375g q6hrs 

Vancomycin 1g q12 hours plus metronidazole 500mg q6 hours (if concerned for MRSA) 

300

In pediatrics settings, the optimal IV antibiotics choice is (dose not required). 

Clindamycin 30mg/kg/day q8hrs and cefotaxime 150mg/kg/day q8hours 

Meropenem, impenem/cilastatin and zosyn 

400

I have drained my adult patient's PTA in the ED. Options for outpatient regimen include: (also include how long the course should be) 

Penicillin VK 500mg every 6 hours and 500mg flagyl evvery 6 hours 

Augmentin 875mg every 12 hours (contraindicated if suspected infectious mononucleosis) 10-14 days. 

500

I drained this PTA and want to discharge my pediatrics patient with outpatient abx course. My options include. Mom tells the pt has a penicillin allergy 

Clindamycin 30mg/kg/day divided every 8 hours 

Third generation cephalosporin (cefdinir) 300mg every 12 hours plus metronidazole 500mg every 6 hours 

Linezolid 600mg every 12 hours plus metronidazole 500 mg every 6 hours (MRSA risk)

Management

100

I attempted to needle aspiration of this PTA. Surprisingly, nothing came out. Another intervention I may try is: (this does not include ENT consult) 

Incision and drainage of PTA 

ENT can always perform quinsy tonsillectomy 

200

True or False: In a Cochrane review in 2016, I&D of a PTA increased recurrence rate in patients >8yo when compared to needle aspiration 

False, needle aspiration had increased rate of recurrence 

300

To ensure highest probability of success, prior to performing intervention on PTA, I can use these medications: 

Parenteral or oral analgesia

Viscous lidocaine 

Cetacaine spray, Benzocaine (Hurricane sray) 

Lidocaine plus epinephrine injection (up to 6-10cc) 

400

My patient is not able to open his/her mouth for needle aspiration of PTA. I remember reading an article about just what to do on ALiEM. Some additional tricks include: 

500

Name 3 indications for admission for patient with PTA

• severe sepsis
• dehydration
• airway compromise (check for kissing tonsils)
• comorbidity and/or immunocompromise
• failure of outpatient management
• diabetes mellitus
• chronic use of immunosuppressive medications (such as prolonged corticosteroid use)

H&P

100

True or False: History and Physical exam is enough to diagnose PTA? 

True 

200

What is the most common pathogen associated with PTA 

Group A strep (strep pyogenes) 

Aerobic: Staph Aureus, H. Influenzae, Corynebacterium 

Anaerobic: Fusobacterium, Peptostreptococcus, Prevotella, Porphyromonas 

300

Which of the following is the greatest social risk factor for development of PTA: 

ETOH Abuse 

Smoking 

Cocaine Abuse 

IVDU 

Smoking 

400

Name four physical exam findings suggestive of PTA 

Uvular deviation 

Enlarged tonsil 

Trismus (difficulty opening mouth due to pain 

Pooling of saliva or drooling 

Rancid breath 

Tender cervical LAD (can be unilateral or bilateral) 

500

What is the age range with highest incidence of PTA 

20-40 

Emergency Complications of PTA Complications

100

My patient has had unilateral throat pain for 3 days, now complaining of painful, productive cough with associated systemic symptoms: Name this complication 

Aspiration pneumonia, pnuemonitis, or lung abscess 

200

Name this complication: I walk in the room and see this. I then start wheeling my patient to the CPR room. 

Airway Obstruction 

300

Name this complication: My patient reports PTA approximately 4  days ago that went away with Abx. Today they are complaining of prolonged fever, sore throat, chills, vomiting, and unilateral neck tenderness

Lemierre's disease: a suppurative thrombophlebitis of the jugular vein. most often caused by anaerobic bacteria (fusobacterium), with pharyngitis as the most common preceding infection 

400

Name this complication: My patient reports fevers, odynophagia, pain on left side of throat for 24 hours. A couple of hours ago, your patient tells you their left arm is now completely numb and weak. 

Extension of infection into tissues of deep neck or posterior mediastinum. 

500

Name this complication: You get called to the CPR room after patient found with copious bleeding from mouth. Dr. Jauch already cric'd the patient and has a finger in the patient's mouth tamponading the bleed with his mere finger. You notice the patient has unilateral tonsil swelling with contralateral uvular deviation. 

hemorrhage from erosion or septic necrosis into carotid sheath