Tinjauan PustakaPeritonsillar abscesses (PTA) are the most common deep neck space infection and are a common complication of tonsillitis with potentially disastrous sequelae 1. Untreated or improperly-treated peritonsillar infection can evolve into a parapharyngeal space abscess, or cause sepsis, airway obstruction, carotid pseudoaneurysm and even death. The two palatine tonsils lie on the lateral walls of the oropharynx in the depression between the anterior tonsillar pillar (palatoglossal arch) and the posterior tonsillar pillar (palatopharyngeal arch). During the embryonic stage, the tonsils arise from the second pharyngeal pouch as buds of endodermal cells. The tonsils form during the last months of gestation and grow irregularly, reaching their largest size at approximately six or seven years of age. The tonsils begin to gradually involute at puberty, and by older age little tonsillar tissue remains 2.Peritonsillar abscesses form in the area between the palatine tonsil and its capsule. If the abscess progresses, it can involve the surrounding anatomy, including the masseter muscles and the pterygoid muscle. If severe, the infection can also penetrate the carotid sheath. The most common organisms associated with peritonsillar abscess are listed in Table 1 . Streptococcus pyogenes (group A beta-hemolytic streptococcus) is the most common aerobic organism associated with peritonsillar abscess. The most common anaerobic organism is Fusobacterium. For most abscesses, a mixed profile of both aerobic and anaerobic organisms cause the infection3-5.TABLE 1Common Organisms Associatedwith Peritonsillar Abscess

AerobicAnaerobic

Streptococcus pyogenesFusobacterium

Staphylococcus aureusPeptostreptococcus

Haemophilus influenzaePrevotella

Neisseria speciesBacteroides

Patients with peritonsillar abscess appear ill and present with fever, malaise, sore throat, dysphagia, or otalgia. The throat pain is markedly more severe on the affected side and is often referred to the ear on the same side.

During the physical examination, trismus (inability or difficulty in opening the mouth) is often present because of inflammation of the pharyngomaxillary space and pterygoid muscle. A distinguishing feature on physical examination is the inferior medial displacement of the infected tonsil with a contralateral deviation of the uvula.Swallowing is also highly painful, resulting in pooling of saliva or drooling. Patients often speak in a muffled voice (also called hot potato voice). Markedly tender cervical lymphadenitis may be palpated on the affected side. Inspection of the oropharynx reveals tense swelling and erythema of the anterior tonsillar pillar and the soft palate overlying the infected tonsil 6.The gold standard for diagnosis of peritonsillar abscess remains the collection of pus from the abscess through needle aspiration. To obtain this sample, the area should be anesthetized with 0.5 percent benzalkonium (Cetacaine spray) followed by a gargle of 2 percent lidocaine (Xylocaine) with epinephrine. A no. 18-gauge spinal needle attached to a 10-mL syringe can be used to obtain material from the suspected abscess. Transcutaneous or intraoral ultrasonography also can be helpful in identifying an abscess and in distinguishing peritonsillar abscess from peritonsillar cellulitis.If spread of the infection beyond the peritonsillar space or complications involving the lateral neck space are suspected, computed tomography (CT) or magnetic resonance imaging (MRI) is indicated 7.CT can distinguish between peritonsillar cellulitis and peritonsillar abscess, as well as demonstrate the spread of the infection to any contiguous spaces in the deep neck region. MRI has the advantage of improved soft-tissue definition over CT without exposure to radiation. Additionally, MRI is superior to CT in detecting complications from deep neck infections such as internal jugular vein thrombosis or erosion of the abscess into the carotid sheath 8.Drainage of the abscess, antibiotics, and supportive therapy to maintain hydration and pain control are the foundation of treatment for peritonsillar abscess. The choice of antibiotics is highly dependent on both the gram stain and culture of the fluid obtained from the needle aspiration. Penicillin used to be the antibiotic of choice for the treatment of peritonsillar abscess, but inrecent years the emergence of beta-lactamase-producing organisms has required a change in antibiotic choice 10. Results of studies suggest that 500 mg of clindamycin administered twice daily or a second- or third-generation oral cephalosporin be used instead of penicillin.Three main surgical procedures are available for the treatment of peritonsillar abscess: needle aspiration, incision and drainage, and immediate tonsillectomy 11. Drainage using any of these methods combined with antibiotic therapy will result in resolution of the peritonsillar abscess in more than 90 percent of cases.Immediate abscess tonsillectomy has not been proven to be any more effective than needle aspiration or incision and drainage, and it is considered to be less cost-effective.Several studies comparing needle aspiration with incision and drainage have found no significant statistical differences in outcomes 9.Antibiotic therapy for peritonsillar abscess is listed in table 2 12.Table 2. Antimicrobial Regimens for Peritonsillar Abscess

Intravenous therapy

Ampicillin/sulbactam (Unasyn) 3 g every six hours

Penicillin G 10 million units every six hours plusmetronidazole (Flagyl) 500 mg every six hours

If allergic to penicillin, clindamycin (Cleocin) 900 mgevery eight hours

Oral therapy

Amoxicillin/clavulanic acid (Augmentin) 875 mg twice daily

Penicillin VK 500 mg four times daily plus metronidazole500 mg four times daily

Clindamycin 600 mg twice daily or 300 mg four times daily