What are the indicators for a peritonsillar abscess?

Clinical Indicators for Peritonsillar Abscess

The diagnosis of peritonsillar abscess is primarily clinical, based on the characteristic triad of severe throat pain, trismus, and "hot potato" voice, combined with physical examination findings of unilateral tonsillar swelling with deviation of the uvula away from the affected side. 1

Key Clinical Presentations

Cardinal Symptoms

• Fever - typically present as a systemic sign of deep infection 1
• Severe throat pain - usually unilateral and more intense than simple pharyngitis 1, 2
• Dysphagia - difficulty swallowing due to pain and anatomic distortion 1
• Trismus - limited mouth opening from inflammation of pterygoid muscles 1, 2
• "Hot potato" voice - muffled speech quality from pharyngeal distortion 1

Physical Examination Findings

• Unilateral peritonsillar swelling with bulging of the soft palate 1
• Uvular deviation away from the affected side 1
• Erythema and edema of the peritonsillar area 2
• Fluctuance may be palpable in established abscess 2

Red Flags Requiring Urgent Intervention

Airway Compromise Indicators

• Stridor or respiratory distress - suggests pharyngeal edema extending to the larynx, which is atypical but life-threatening 3
• Inability to handle secretions - indicates severe swelling 4
• Tachypnea - may reflect both fever and airway narrowing 4

Systemic Sepsis Signs

• Severe systemic symptoms including hypotension or altered mental status 4
• Signs of sepsis - tachycardia, hypotension, altered mental status requiring immediate hospitalization 4
• Volume depletion - common from fever, poor oral intake, and tachypnea 4

Extension Beyond Peritonsillar Space

• Neck swelling or stiffness - suggests extension to retropharyngeal or parapharyngeal spaces 5
• Persistent fever despite drainage - may indicate deep neck space involvement 5
• Mediastinal symptoms - chest pain or dyspnea suggesting descending infection 5, 3

Diagnostic Confirmation

When Imaging Is Indicated

• Atypical presentation where clinical diagnosis is uncertain 6
• Suspected deep neck space extension - CT scan is the modality of choice 2
• Intraoral ultrasound can be helpful for confirming abscess versus cellulitis 6
• Pharyngeal edema extending behind or below the tonsil requires imaging to assess extent 3

Clinical Diagnosis Sufficiency

Most cases can be diagnosed clinically without imaging - the combination of characteristic symptoms and unilateral peritonsillar bulging with uvular deviation is sufficient to proceed with drainage 1, 2

Common Pitfalls to Avoid

• Do not delay drainage for imaging in patients with classic presentation - needle aspiration serves as both diagnostic confirmation and therapeutic intervention 2
• Do not miss bilateral involvement - while rare, bilateral abscesses can occur and require careful examination of both sides 5
• Do not overlook volume depletion - aggressive hydration is essential as patients are commonly dehydrated 4
• Do not rely on antibiotics alone - source control through drainage is essential for treatment success 4

Recurrence Risk Factors

• History of more than one peritonsillar abscess - this is a modifying factor that favors tonsillectomy as definitive treatment 7, 4
• Incomplete drainage - may lead to persistent infection requiring repeat intervention 4