2/10/2018 Tonsillitis and Peritonsillar Abscess Workup: Approach Considerations, Lab Studies, Imaging Studies

Tonsillitis and Peritonsillar Abscess Workup

Updated: Jan 19, 2017
Author: Udayan K Shah, MD, FACS, FAAP; Chief Editor: Arlen D Meyers, MD, MBA more...

WORKUP

Approach Considerations
Tonsillitis and peritonsillar abscess (PTA) are clinical diagnoses. Testing is indicated when group A
beta-hemolytic Streptococcus pyogenes (GABHS) infection is suspected. Throat cultures are the
criterion standard for detecting GABHS. For patients in whom acute tonsillitis is suspected to have
spread to deep neck structures (ie, beyond the fascial planes of the oropharynx), radiologic imaging
using plain films of the lateral neck or CT scans with contrast is warranted. In cases of PTA, CT
scanning with contrast is indicated.

Test the patient's family members for the presence of streptococcal antibodies to detect carriers of
group A Streptococcus (especially family members who are immunocompromised).

Lab Studies
Throat cultures are the criterion standard for detecting group A beta-hemolytic Streptococcus
pyogenes (GABHS). GABHS is the principal organism for which antibiotic therapy (sensitivity 90-95%)
is definitely indicated. Growing concerns over bacterial resistance make monitoring acute tonsillitis
with throat swabs for culture and sensitivity an important endeavor. Relying only on clinical criteria,
such as the presence of exudate, erythema, fever, and lymphadenopathy, is not an accurate method
for distinguishing GABHS from viral tonsillitis. A Monospot serum test, CBC count, and serum
electrolyte level test may be indicated.

A rapid antigen detection test (RADT), also known as the rapid streptococcal test, detects the
presence of GABHS cell wall carbohydrate from swabbed material and is considered less sensitive
than throat cultures; however, the test has a specificity of 95% or more and produces a result in
significantly less time than that required for throat cultures. A negative RADT requires that a throat
culture be obtained before excluding GABHS infection.

A culture or RADT is not indicated in most cases following antibiotic therapy for acute GABHS
pharyngitis. Routine testing of asymptomatic household contacts is similarly not usually warranted.

Serum may be examined for antistreptococcal antibodies, including antistreptolysin-O antibodies and
antideoxyribonuclease (anti-DNAse) B antibodies. Titers are useful for documenting prior infection in
persons diagnosed with acute rheumatic fever, glomerulonephritis, or other complications of GABHS
pharyngitis.

Laboratory evaluation in chronic tonsillitis relies upon documentation of results of pharyngeal swabs or
cultures taken during prior episodes of tonsillitis. The usefulness and cost of throat swabs for
pharyngitis are debated.

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2/10/2018 Tonsillitis and Peritonsillar Abscess Workup: Approach Considerations, Lab Studies, Imaging Studies

Imaging Studies
Routine radiologic imaging is not useful in cases of acute tonsillitis. For patients in whom acute
tonsillitis is suspected to have spread to deep neck structures (ie, beyond the fascial planes of the
oropharynx), radiologic imaging using plain films of the lateral neck or CT scans with contrast is
warranted.

In cases of peritonsillar abscess (PTA), CT scanning with contrast is indicated in general [13] for
unusual presentations (eg, an inferior pole abscess) and for patients at high risk for drainage
procedures (eg, patients with coagulopathy or anesthetic risk).

CT scanning may be used to guide needle aspiration for draining PTAs after an unsuccessful surgical
attempt and for draining abscesses that are located in unusual locations and are anticipated to be
difficult to reach with standard surgical approaches. Hatch and Wu mentioned ultrasonography as
another means of guidance in PTA drainage. [14]

A study by Huang et al indicated that ultrasonography is an accurate means of evaluating patients for
PTA, finding that compared with patients diagnosed with PTA via traditional examination methods
and/or CT scanning, those who were diagnosed with transcervical ultrasonography demonstrated
significant reductions in surgical drainage and length of hospital stay. [15]

Treatment & Management

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