INTRODUCTION
The boundaries of the peritonsillar space include the palatine tonsil medially, the superior constrictor muscle laterally, and the anterior and posterior tonsillar pillars. The peritonsillar space is composed of loose connective tissue and tonsillar vasculature, making this potential space prone to developing fluid collections in the setting of infection.
Peritonsillar abscesses are most common in the second and third decades of life and typically develop after episodes of acute tonsillitis. While patients with acute tonsillitis generally present with bilateral symmetric tonsillar enlargement, patients with a peritonsillar abscess usually present with trismus, asymmetric unilateral soft palate fullness, medial displacement of the ipsilateral tonsil, and contralateral uvular deviation. However, there are rare instances in which patients may present with concurrent bilateral peritonsillar abscesses.
INDICATIONS
Peritonsillar phlegmon without a rim-enhancing fluid collection and small peritonsillar abscesses may be treated with medical management alone. Surgical management with needle aspiration or incision and drainage is recommended for peritonsillar abscesses larger than 1 to 1.5 cm.
TECHNIQUE
Equipment
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Headlight and tongue depressors
OR
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Laryngoscope handle and MAC 3 or 4 blade
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Benzocaine or Cetacaine spray
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Alternatives: 2% viscous lidocaine, 4% topical lidocaine
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10 mL Luer-Lok syringe
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18-gauge needle, 1.5″ or spinal needle (3.5″)
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25- or 27-gauge needle
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1% lidocaine with 1:100,000 epinephrine
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No. 11 or 15 blade scalpel
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Hemostat forceps
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Cup of ice water
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Emesis bag or kidney basin
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Suction setup at bedside with Yankauer tip
Optional:
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Culture swab
Note: Many components listed above including needles, syringes, scalpel, and hemostat forceps may be found within a laceration repair tray.
Anesthesia
Needle aspiration and incision and drainage are usually performed using topical and/or local anesthesia. Patients remain fully awake. Pain medications may be administered 30 minutes to 1 hour before the procedure as well.
Spray the soft palate with one unit or 1 to 2 sprays of topical anesthetic such as benzocaine or Cetacaine. If topical spray is unavailable, patients can gargle 2% or 4% lidocaine and then spit out the solution. Allow the anesthetic 2 to 5 minutes to take effect.
For additional local anesthesia, inject 1 to 2 mL of 1% lidocaine with 1:100,000 epinephrine into the mucosa of the lateral soft palate along the area of the planned aspiration and incision. Occasionally, purulence can start draining with the lidocaine injection. Patients can also experience pain and pressure with the lidocaine injections that may match or exceed the pain associated with the therapeutic aspiration itself. Therefore, lidocaine injections are not ideally performed in the pediatric population.
Preparation
Obtain consent for transoral peritonsillar abscess needle aspiration and incision and drainage. Discuss possible complications including pain, bleeding, aspiration, reaccumulation or recurrence of the abscess, and the remote but potential risk of carotid artery injury.
The patient is positioned in an upright position with the patient resting against the back of an exam chair if possible, in order to deter backwards motion during the procedure. This position also helps to prevent aspiration of purulence and blood from the procedure. Adjust the height of the exam chair to maximize visualization of the oropharynx, which should be at eye level for the clinician.
Clear visualization of the oropharynx is a key component of successful drainage. One method is to wear a headlight and use one or two tongue depressors to inferiorly displace the tongue. Another method is to have the patient hold a laryngoscope blade, which has its own light source. The second option is preferable as having patients hold the laryngoscope improves patient comfort and additionally allows the practitioner to perform the procedure with two hands.
The patient should hold the Yankauer suction in the other hand and use it as needed for secretions and drainage throughout the procedure.
Needle Aspiration
An 18-gauge needle is typically used for aspiration. There are two lengths of needles that are typically used: the standard 1.5″ or spinal needle (3.5″).
If imaging is available, the exact depth to the center of the abscess may be measured and utilized in planning the depth of needle insertion. Cross-sectional imaging can also help localize the abscess and identify the distance to the carotid artery.
If using the shorter 1.5″ needle, direct visualization is used to confirm the appropriate depth of needle insertion.
If using the spinal needle, remove and trim 1 to 1.5 cm from the outer plastic sheath. Replace the sheath over the needle with the newly cut end away from the needle tip and leaving only a small portion of the needle exposed. With this technique, the plastic sheath acts as a guard and limits needle insertion to the predetermined depth when the plastic sheath is sitting flush against the soft palate.
The wide-bore needle attached to a 10 mL syringe is used to aspirate fluid from the peritonsillar space at the area of maximal edema or fluctuance along the soft palate. The target area can also be identified as lateral to the intersection of the anterior tonsillar pillar and the base of the uvula. Once the needle tip has fully entered the mucosa, maintain negative pressure during aspiration by pulling back on the control top syringe while advancing the needle. Multiple attempts to localize the abscess pocket and minor adjustments to the angle of needle insertion may be necessary. Avoid deep and lateral orientation of the needle as this is in the direction of the carotid artery.
A smaller 5-mL syringe may be utilized in the pediatric population or cases in which the patient’s trismus precludes use of a 10-mL syringe.
Needle aspiration only may be more appropriate for the pediatric population who can tolerate a bedside procedure.
Incision and Drainage
Once the abscess has been localized using needle aspiration, incision and drainage is performed to ensure complete evacuation of the abscess. Similar to the needle sheath, the plastic scalpel sheath can be measured and used as a guard for the scalpel although this is not usually necessary. Using the needle aspiration site as guidance, make a 1- to 2-cm incision using the scalpel through the soft palate mucosa and submucosa parallel to and 1 cm posterior to the edge of the anterior tonsillar pillar.
Once the incision is complete, hemostat forceps are used to dissect in the pocket and break any loculations. The Yankauer suction may also be used to apply gentle pressure to the soft palate to remove any additional purulence from the peritonsillar space. This incision is left open as an egress pathway to further drain.
Optional: Irrigation of the peritonsillar pocket may be considered. The abscess pocket can be gently irrigated using an 18-gauge Angio catheter attached to a syringe filled with sterile saline.
When there is prominent peritonsillar fluctuance on exam, it may be appropriate to proceed directly with incision and drainage since localization of the abscess is not necessary.
For both methods, bleeding should be minimal and is controlled using ice water gargles. Afrin may be added to the ice water gargles if needed for further hemostasis.
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