The recent history may include a sore throat with unilateral pain, malaise, low-grade pyrexia, chills, diaphoresis, dysphagia, reduced oral intake, trismus, and a muffled “hot potato voice.” Trismus results from irritation and reflex spasm of the internal pterygoid muscle. Impaired palatal motion from edema contributes to the muffled voice. Physical examination reveals minimal to moderate toxicity, dehydration, and drooling. Inspection of the oropharynx may be compromised by trismus. The soft palate is displaced toward the unaffected side, is swollen and red, and is frequently palpably fluctuant. The edematous uvula is pushed across the midline. The displaced tonsil and its crypts are rarely coated with exudate. The breath is fetid, and ipsilateral, tender, cervical adenopathy is present.

The white blood cell count is elevated, with a predominance of polymorphonuclear leukocytes. Brodsky and associates attempted to identify the clinical signs that could distinguish peritonsillar abscess from peritonsillar cellulitis in a group of 21 children admitted to the Children’s Hospital of Buffalo, New York, from 1985 through 1987. No significant difference in age, duration of sore throat, fever, or white blood cell count was noted, although a greater degree of pharyngotonsillar bulge and muffled voice was found in the patients with abscess. However, patients with peritonsillar cellulitis improved after receiving 24 hours of intravenous antibiotics, whereas patients with peritonsillar abscess had no change or worsening of symptoms. Blotter and colleagues confirmed these findings in a group of 102 patients admitted to Children’s Hospital of Columbus, Ohio, between 1995 and 1998.

Traditionally, management of peritonsillar abscess in children involved hospital admission for intravenous hydration, antibiotic therapy and analgesia, and either intraoral incision and drainage of the abscess or “acute quinsy tonsillectomy” with removal of the medial wall of the abscess. Acute tonsillectomy was often performed to prevent future recurrence of the peritonsillar abscess.

Studies have suggested that many peritonsillar abscesses can be managed by simple needle aspiration combined with antibiotic therapy on an outpatient basis. An extensive metaanalysis by Herzon of 10 previous studies conducted from 1961 through 1994 involving 496 patients with peritonsillar abscesses found an overall success rate of needle aspiration of 94% (range, 85% to 100%). This success rate compares favorably with the success rate reported for incision and drainage. Weinberg and associates successfully performed needle aspiration in 41 of 43 children, aged 7 to 18 years, with a mean age of 13.9 years. All were admitted for intravenous antibiotic therapy, two (5%) required repeat aspiration for resolution, and five (12%) did not respond and required acute tonsillectomy. Other studies, which have included both adults and children with peritonsillar abscesses, have reported that 0% to 14% of
patients required hospitalization, although the ages of the patients requiring hospitalization was not reported. Younger children often require admission to correct dehydration. Younger children are also more likely than older children to respond to intravenous antibiotics alone and to have negative findings at surgical drainage. The use of conscious sedation has been reported to be a safe and effective approach for the drainage of peritonsillar abscesses in children.

A suggested approach to the management of children with peritonsillar abscess is as follows. Cooperative children should undergo needle aspiration of the abscess and treatment with antibiotics. Children who can tolerate liquids orally may be managed as outpatients, and the remainder should be admitted for hydration and intravenous antibiotics. Approximately 4% of children will require a repeated aspiration for resolution. Children who remain symptomatic after undergoing needle aspiration require incision and drainage or acute quinsy tonsillectomy depending on the prior history of recurrent tonsillitis. Children who cannot tolerate needle aspiration on initial presentation are admitted for administration of intravenous antibiotics. If no response occurs within 24 hours, incision and drainage or acute tonsillectomy is performed depending on the prior history of recurrent tonsillitis. Delayed tonsillectomy is reserved for children who recover from the peritonsillar abscess without general anesthesia but have a history of recurrent tonsillitis or prior peritonsillar abscess.

Untreated peritonsillar abscess may point, with spontaneous rupture, or may extend to the parapharyngeal space with potentially fatal complications. Upper airway obstruction, septicemia, and vascular catastrophe may occur. Necrotizing fasciitis has also been reported in adults with peritonsillar abscess.

The symptoms of retropharyngeal abscess frequently begin insidiously after mild antecedent infection. No trismus occurs, but a stiff neck secondary to muscle tenderness may be present along with an ipsilateral tender cervical adenopathy. Although classic teaching described stridor and upper airway obstruction in children with retropharyngeal abscesses, more recent reviews have shown that these symptoms are uncommon in children, most likely because children are presenting earlier in the course of the disease. Early in the course, midline or unilateral swelling of the posterior pharynx occurs. Later, gentle palpation may demonstrate a large, fluctuant mass in the posterior pharynx. Posterior mediastinitis can result from the spread of infection from the retropharyngeal area into the prevertebral space. Other complications may be seen when the abscess extends to the parapharyngeal space and involves the great vessels and cranial nerves.

As with other abscesses, the white blood count is increased, with a predominance of granulocytes. Plain films of the neck are often the initial radiologic study performed but must be taken with the patient in a true lateral position, with the neck in extension, and on inspiration, or the child’s retropharyngeal soft tissues may appear abnormally thickened. Widening of the prevertebral soft tissues exceeding the anteroposterior diameter of the contiguous vertebral bodies or thickening of the retropharyngeal space greater than 7 mm at C2 in both children and adults, or 14 mm at C6 in children or 22 mm at C6 in adults, suggests retropharyngeal inflammation.

Computed tomography (CT) scanning has made the diagnosis and management of deep neck space infections more precise. In contrast to conventional radiologic studies, the CT scan distinguishes cellulitis of the neck, which usually does not require surgical treatment, from a deep neck abscess, which requires surgical drainage. With its ability to define differences in tissue density, CT scanning permits accurate determination of the extent of the abscess and its extension and involvement of adjacent spaces. An abscess is distinguished from cellulitis by a low-attenuation homogeneous area surrounded by a ring enhancement of contrast material. Kirse and Roberson reported scalloping of the abscess wall to be a more useful predictor of the presence of pus than ring enhancement (Fig. 249.1).

A 10-year retrospective study from the Massachusetts Eye and Ear Infirmary compared preoperative CT scans with intraoperative findings in 38 patients who underwent surgical exploration of the parapharyngeal or retropharyngeal space within 48 hours after the scans were performed. Overall, the intraoperative findings confirmed the CT scan interpretation in 76.3% of the patients. Of the 38 patients, 5 (13.2%) had CT scans indicative of abscesses that were not confirmed at surgery. Exploration of the parapharyngeal or retropharyngeal space revealed cellulitis. The false-negative rate was 10.5%. The sensitivity of CT scanning for detection of parapharyngeal or retropharyngeal space abscess was 87.9%.

Treatment consists of administration of intravenous antibiotics and incision and drainage through a peroral incision with the patient in the Rose position (supine with the neck hyperextended). Some reports have documented that patients with small retropharyngeal abscesses may respond to treatment with intravenous antibiotics alone. Broughton described the experience at the University of Kentucky Medical Center, in which 8 (57%) of 14 patients with deep neck infections seen during a 9-year period were treated successfully by antibiotics alone. All were reported to have small abscesses on CT scan. However, possibly some had only cellulitis. Craig and Schunk described the successful treatment of 10 (38%) of 27 patients with retropharyngeal abscesses on CT by intravenous antibiotics alone. Close clinical follow-up is mandatory for children
treated with intravenous antibiotics alone. Children who do not improve within 24 to 48 hours require surgical drainage.