PTA or cellulitis is usually secondary to local spread from pharyngeal infections The palatine tonsils are located between the palatoglossal and palatopharyngeal arches The tonsils are surrounded by a capsule which covers part of the tonsil and is responsible for housing neurovascular structures PTAs develop in the potential space between the capsule and the constrictor muscles (tonsil bed) An infection within the tonsil capsule is an intratonsillar abscess Clinical differentiation can be difficult PTA develops in the potential space between the capsule and the constrictor muscles (tonsil bed) An infection within the tonsil capsule is an intratonsillar abscess If untreated, infection or inflammation may spread from that abscess to contiguous structures such as the masseter or pterygoid muscles PTAs are more commonly seen in adolescents and young adults, though they can present in younger children as well Infections in the peritonsillar space are usually polymicrobial, including bacteria such as group A streptococci, anaerobic bacteria, and potentially S aureus Clinical Considerations Clinical Recognition Patients with tonsillitis often present with fever, sore throat, and lymphadenopathy Patients are usually able to open their mouths fully, and have diffuse erythema and often exudate present on examination The symptoms and examination findings are typically bilateral When patients present with associated URI symptoms such as cough and rhinorrhea, bacterial etiologies are less common (see Chapter 74 Sore Throat ) Peritonsillar cellulitis and abscess also often present with fever and sore throat PTA often presents with difficulty opening the mouth, or trismus, which can help the provider differentiate from simple tonsillitis or cellulitis Additionally, the patients may have difficulty handling their secretions, asymmetric palate swelling and erythema, and have voice changes including sounding “muffled” or speaking with a “hot-potato” voice Triage Considerations Immediate assessment of the airway is paramount in patients with tonsillar infections If patients have evidence of stridor or pooling secretions, alternative diagnoses such as supraglottitis, and, more rarely, epiglottitis should be considered If the airway is in jeopardy, the patient should ideally have all airway interventions performed in the operating room with an anesthesiologist and otolaryngologist present If the patient is stable without evidence of airway compromise, triage should focus on pain control, accurate diagnosis, and appropriate consultation, if necessary Clinical Assessment Peritonsillar cellulitis is characterized by erythematous, painful tonsils, with or without exudate It may be bilateral, and is not routinely associated with uvular deviation or significant trismus PTAs are often characterized by fever, trismus, and muffled voice Physical examination findings consistent with a PTA include a bulging, erythematous tonsil with swelling of the soft palate due to the abscess collection causing the base of the uvula to deflect away from the midline toward the unaffected side The tonsil may have exudate, but the symptoms are frequently unilateral (see Fig 118.3 ) Bilateral PTA is rare, but may cause anterior displacement of the uvula Management and Disposition Peritonsillar cellulitis should be treated with IV antibiotics, given the frequent severity of symptoms and the risk of progression to more serious illness Common antibiotic choices include clindamycin (40 to 45 mg/kg/day divided TID) or ampicillin-sulbactam (200 mg/kg/day divided q6), both IV PTA usually requires surgical drainage If the provider is experienced in performing incision and drainage or needle aspiration, then they should perform the procedure themselves In pediatrics, otolaryngology is frequently consulted to assist in this procedure, either in the ED or in the OR In older, cooperative patients, the procedure can often be performed without sedation in the ED Following drainage or aspiration, patients should be treated with antibiotics If patients are improved and able to tolerate oral antibiotics, discharging them on a course of amoxicillin-clavulanate (80 to 90 mg/kg/day divided BID, max single dose 875 mg) or clindamycin (40 to 45 mg/kg/day divided TID, max single dose 600 mg) is indicated If they require admission, then treatment with ampicillinsulbactam or clindamycin as with cellulitis is indicated FIGURE 118.3 Peritonsillar abscess Note the left-sided bulging, erythematous tonsil protruding into the uvula, causing deviation into the side of the unaffected tonsil (From Jensen S Nursing Health Assessment 2nd ed Philadelphia, PA: Wolters Kluwer; 2014.) RETROPHARYNGEAL AND PARAPHARYNGEAL INFECTIONS Goals of Treatment Deep space neck infections, such as retropharyngeal and parapharyngeal infections, can be challenging for the emergency physician as well as potentially life threatening for the patient Rapid and accurate identification of deep space neck infections is vital in their treatment, given the risk of upper airway obstruction or systemic illness Providers must also provide appropriate disposition for patients with deep space neck infections, either as hospitalized inpatients or to the operating room for definitive incision and drainage CLINICAL PEARLS AND PITFALLS Patients less than year old with deep space neck infections may present with little more than fever and fussiness Initial antibiotic choices for patients with deep space neck infections include ampicillin-sulbactam or clindamycin Clindamycin has superior MRSA coverage but has a less palatable transition to oral therapy Current Evidence A retropharyngeal abscess occurs in the potential space between the prevertebral fascia and the posterior pharyngeal wall This retropharyngeal space contains two chains of lymph nodes that are prominent in younger children, but often disappear by puberty These nodes can become enlarged and necrotic in the setting of upper respiratory tract infections, and subsequently become infected The usual pathogens are group A streptococci, anaerobic organisms, and occasionally S aureus These infections occur most often in children younger than years A lateral pharyngeal (or parapharyngeal) abscess occurs in the deep soft tissue space of the neck as well, but not in the midline, and is less common than a retropharyngeal infection in the younger patient population Clinical Considerations Clinical Recognition Patients with deep space neck infections often present with fever and appear quite ill Patients presenting early in the course of illness may be diagnosed with simple pharyngitis; progression of the abscess manifests with sore throat, difficulty swallowing, stiff neck, muffled voice, and, late in the course, rarely stridor Often, there is a history of a preceding viral upper respiratory infection Triage Considerations Patients with deep space neck infections are often ill appearing Evidence of upper airway obstruction such as tripod positioning, difficulty with handling secretions, or stridor should be immediately evaluated by a provider If patients are severely ill with respiratory distress, an otolaryngology evaluation should be obtained promptly Initial Assessment Particular attention should be paid to signs of upper airway obstruction on physical examination Patients may put themselves in a position of comfort Those with more advanced disease may show signs of severe distress such as ... incision and drainage or needle aspiration, then they should perform the procedure themselves In pediatrics, otolaryngology is frequently consulted to assist in this procedure, either in the ED... neck infections, such as retropharyngeal and parapharyngeal infections, can be challenging for the emergency physician as well as potentially life threatening for the patient Rapid and accurate identification