What are the next steps for a patient with a peritonsillar abscess experiencing difficulty breathing and drooling?

Management of Peritonsillar Abscess with Airway Compromise

Immediate airway management with rapid sequence intubation by the most experienced clinician is required for a patient with peritonsillar abscess presenting with difficulty breathing and drooling, as these are signs of impending airway obstruction.

Initial Assessment and Stabilization

Signs of Airway Compromise

• Difficulty breathing
• Drooling
• Other concerning signs may include:
  • Stridor
  • "Hot potato" voice
  • Trismus (limited mouth opening)
  • Dysphagia
  • Muffled voice

Immediate Actions

1. Call for help immediately - summon the most experienced airway manager available 1
2. Position the patient - upright position if tolerated to maximize airway patency
3. Administer supplemental oxygen - high-flow oxygen via face mask
4. Prepare for definitive airway management - this is not a "wait and see" situation

Definitive Airway Management

Equipment Preparation

• Prepare for rapid sequence intubation (RSI)
• Have difficult airway equipment immediately available:
  • Video laryngoscope (preferred first-line device)
  • Bougie
  • Supraglottic airway devices (second-generation preferred)
  • Surgical airway equipment (scalpel-bougie-tube)

Intubation Approach

1. RSI by most experienced clinician 1

   • Consider modified RSI with maintenance of spontaneous ventilation if severe obstruction
   • Avoid multiple attempts - transition through algorithm promptly if difficulty encountered
   • Use video laryngoscopy if available to improve first-pass success

2. If intubation fails:

   • Attempt supraglottic airway (SGA) placement
   • If SGA fails, move quickly to surgical airway (front-of-neck access)
   • Follow the "can't intubate, can't oxygenate" protocol 1

Special Considerations

• Avoid nasotracheal intubation due to increased stimulation of airway reflexes 2
• Consider awake intubation only if patient is stable, cooperative, and has minimal airway edema 1
• Have surgical backup ready for emergency surgical airway if needed

Post-Intubation Management

1. Confirm tube placement with continuous waveform capnography

2. Secure the tube and record depth of insertion

3. Administer antibiotics effective against group A streptococcus and oral anaerobes 3, 4

   • Penicillin plus metronidazole
   • Clindamycin
   • Appropriate cephalosporins

4. Abscess drainage once airway is secured:

   • Needle aspiration is the gold standard for initial drainage 5
   • Surgical incision and drainage for larger abscesses
   • Consider immediate tonsillectomy in severe cases 4

5. Supportive care:

   • IV hydration
   • Pain control
   • Consider corticosteroids to reduce inflammation and speed recovery 4

Complications to Monitor

• Extension of infection into deep neck spaces
• Aspiration
• Sepsis
• Mediastinitis
• Jugular vein thrombosis

Common Pitfalls to Avoid

1. Delayed recognition of airway compromise - drooling and respiratory distress are late signs requiring immediate action
2. Multiple intubation attempts - limit attempts and progress through algorithm quickly
3. Inadequate preparation - always have difficult airway equipment and surgical backup ready
4. Inappropriate antibiotic selection - must cover both aerobic and anaerobic organisms

Remember that peritonsillar abscess with airway compromise represents a true emergency. The priority is securing the airway before proceeding with definitive treatment of the abscess itself.